SASTRE, LAUREN ROGERS, Ph.D. Let’s Talk About Food: An Examination of the Dietary and Health Perceptions, Behaviors, Knowledge, and Interests of Newcomer Youth and Caregivers. (2016) Directed by Dr. Lauren Haldeman. 172 pp.

The overall purpose of this research was to examine the dietary and health

perceptions, behaviors, knowledge, and interests of newcomer youth (ages 12–17) and

caregivers.

This work included three components: facilitated discussions with caregivers,

facilitated discussion and semi-structured interviews with adolescents, and a survey

(including BMI assessment) with adolescents. In the first phase, the focus groups with

caregivers (n=38) revealed interest in receiving community based nutrition education,

assistance utilizing food labels, learning to cook and taste test local/American foods, as

well as diet-related chronic disease concerns. Caregivers also expressed concern

regarding the lack of healthy options in restaurants and lack of fruits and vegetables in

their children’s diets.

In the second phase, a facilitated discussion and semi-structured interviews were

conducted with adolescents (n=9) which focused on changes to diet and physical activity

as well as nutrition and health literacy. Themes identified via content analysis revealed

consistent perceptions of reductions in physical activity upon arrival. Participants

consistently described the many ways they were active prior to arriving to the U.S. and

the limited current opportunities. This was in contrast to dietary changes, in which

participants reported their diets to be similar to pre-arrival (however, they also listed a

variety of new foods they were eating after arrival to the U.S.). Participants described

health as a concept of “balance” (e.g., limiting junk, sugar, fat, and salt, and eating fruits

and vegetables) and also mentioned the value of physical activity in supporting health.

Female participants expressed many concerns regarding weight gain and a desire to lose

weight.

In the third phase, a survey and BMI data were collected from adolescents (n=67).

Approximately one-third (31.5%) were overweight/obese. Nearly 46% (45.8%) reported

they believe their weight to be “good” and participants with positive body satisfaction

were more likely to be within the normal BMI range (p=0.010). Nearly 47% (46.8%)

have tried to lose weight. Dietary acculturation scores were marginally (and positively)

associated with BMI (p=0.057). Significant relationships between dietary acculturation

and the value of convenience (p=0.003) and observing Americans eat foods (p=0.030)

were also identified. Taste and cost were also significantly associated with BMI with

those with a higher BMI more likely to value taste and less likely to be concerned with

cost (p=0.010 and p=0.009, respectively). Just over 85% (85.3%) had tried four or more

new foods and the largest factors influencing food choices included health (70.1%), taste

(55.2%), religion (45.3%), and convenience (44.6%). Significant increases in

consumption of milk, fruit juice, soda, and meat were identified between pre- and post-

arrival reported intake frequencies (p=0.009, p=0.002, p=0.026, and p=0.010,

respectively). Students reported they wished to be more physically active (84.8%) and

have more opportunities to play more sports (84.7%). Students were more likely to

associate physical activity with health in comparison to diet (83.1% vs. 41.5%), and

56.7% agreed with the statement “I am healthy.”

This work suggests many areas of concern for newcomer adolescents including

body dissatisfaction and poor body image, limited access to physical activity, and rapid

dietary changes (negative and positive), as well as many areas of interest for nutrition

education with caregivers. Many areas of concern as well as of interest were identified in

this newly-arrived and diverse study population that may guide future nutrition education

and health promotion research and programming.

LET’S TALK ABOUT FOOD: AN EXAMINATION OF THE DIETARY AND

HEALTH PERCEPTIONS, BEHAVIORS, KNOWLEDGE, AND

INTERESTS OF NEWCOMER YOUTH

AND CAREGIVERS

by

Lauren Rogers Sastre

A Dissertation Submitted to the Faculty of The Graduate School at

The University of North Carolina at Greensboro in Partial Fulfillment

of the Requirements for the Degree Doctor of Philosophy

Greensboro 2016

Approved by Dr. Lauren Haldeman Committee Chair

 

ii

APPROVAL PAGE

This dissertation, written by Lauren Rogers Sastre, has been approved by the

following committee of the Faculty of The Graduate School at The University of North

Carolina at Greensboro.

Committee Chair

Committee Members

Date of Acceptance by Committee Date of Final Oral Examination

 

iii

ACKNOWLEDGMENTS

I would like to first thank my mentor and chair Dr. Lauren Haldeman. She has

always supported my interests and goals and she has taught me many personal lessons

that exceed academia. I am truly blessed and grateful for her. I would also like to thank

my committee members Dr. Jigna Dhaord, Dr. Lenka Shriver, and Dr. Sharon Morrison. I

am grateful for their support and input which helped shape this work and sharpen my

skills as a researcher. I would also like to thank Ms. Burgin Ross, who has been one of

my greatest supporters and mentors as a graduate student.

I would also like to thank the school staff who made this research possible,

especially the principal, social worker, janitor, community liaisons, and the PE and Art

teachers. I would like to thank the many research assistants, translators, and/or

interpreters with whom I worked, as I could not have done this work without each and

every one of these individuals.

I would like to thank my parents for raising me to be curious, exploratory, and to

ask questions. I would like to thank my great grandfather Carl Shelton and my

grandmother Margaret Rogers for initiating my interest in other cultures and in social

justice. I would like to dedicate this work to my Abuela by marriage Raquel Sastre and

her son, my father in law Aristides Sastre who (in addition to their family) bravely left

their home in Cuba to be “newcomers” here in the U.S. I am especially grateful for their

grandson and son who is my biggest supporter, encourager, and the love of my life—my

husband Cameron Sastre. I would also like to dedicate this work to my two sons James

 

iv

and Theodore who have kept me balanced and who have ensured I always have

something to smile about. Thank you!

 

v

PREFACE

I can remember as a young child visiting my maternal great grandparents and

paternal grandparents and observing the various items they brought home from their

world travels (e.g., hunting masks and spears from Kenya, glass from Italy, porcelain

from Britain, steins from Germany). I remember listening to stories my paternal

grandparents would tell from having lived all over the world and tasting dishes and foods

they picked up along the way. I can remember growing up and loving any opportunity to

do a project on a population or a country and learn about what they ate, how they did

things, social customs, the geography—everything that was new, unique, and different

than my life and experience here in the U.S. I still remember completing a project in the

third grade about China and gluing rice into the corner of the poster board to represent the

staple of the diet.

I believe my interests in other cultures, in addition to a desire to work with groups

experiencing health disparities, lead to my interest in the newcomer’s experience.

Newcomer households have been associated with elevated levels of food insecurity,

chronic disease and/or malnutrition risks, limited access to quality healthcare, poverty,

and difficulty navigating the American life and systems (e.g., medical services, grocery

stores) upon arrival in addition to cultural and language barriers. Some research also

suggests, due to globalization, that many groups are being exposed to components of the

westernized diet and convenience foods and snacks prior to arrival to the U.S.,

 

vi

demonstrating a more complex picture of dietary acculturation or “dietary change” in the

U.S.

Newcomer youth (in contrast to young children) have more memory of their

previous culture and dietary habits as well as cultural health beliefs; however, they will

be thrust full force into American culture as they enter the public school system. They are

unique in the time of their life in which they are physically (e.g., bone mass) and socially

developing as adults (e.g., more independence over diet). Newcomer youth have also

been suggested to play an integral role as cultural and lingual brokers, helping parents

navigate their new life and may have a unique influence and control over household

decisions. In addition, newcomer youth have been reported to experience rapid dietary

acculturation with many new negative behaviors (e.g., fast food, convenience foods).

Caregivers and youth, particularly from some more recent incoming groups, are

understudied, and newcomer youth specifically are understudied despite suggested high

levels of health and nutrition related risks.

To begin my work, I conducted a preliminary study in which I interviewed service

providers (n=40) with a wide range of expertise (e.g., physicians, nurses, resettlement

caseworkers, ESL teachers, faith-based volunteers, etc.) from Guilford County, a diverse

and central county located in the piedmont of North Carolina with a large immigrant and

refugee population (60,000+ locally). I found perceptions were consistent across

participants.

 

vii

Resettlement housing was reported to be in poor condition, located in areas of

poverty with transportation barriers. Refugees rarely relocate due to strong community

relationships and support. Perceived dietary risks included difficulties budgeting and

maintaining food assistance, hoarding food, high consumption of sodas and sweets, and

limited health knowledge. Youth were reported to be exposed and rapidly acculturate to

western foods, which caused stress and frustration for their parents. Respondents reported

that most refugee groups prefer “fresh” foods, have strong agricultural skills, and lack

green space. Major barriers to health care reported were poverty, short duration of initial

Medicaid coverage, and language (both lack of interpretation services and translated

materials). A variety of chronic conditions were consistently observed with type 2

diabetes, weight gain, and dental problems being the most frequently reported conditions

across groups.

The high level of chronic disease risk and concerns with these groups, in addition

to generational differences in dietary acculturation, became the focal point for this

research. I was interested in what the parents needed and the unique perceptions and

changes the youth experience. Lastly, I was curious about trends due to common

experience as a “newcomer” and also how groups varied in their approach to and

perception of changes, experiences, knowledge, and interests. What is similar between

newcomers as they are “new” to the U.S. and what is unique because of variances in

culture, religion, gender, and experiences prior to arrival? What do they try first? Why?

How are new things introduced? What is valued and would drive healthier choices? This

 

viii

research seeks to fill some of the many gaps within the literature so that these

understudied (and often marginalized groups) may be better understood to support their

nutrition and health in the future.

 

ix

TABLE OF CONTENTS

Page

LIST OF TABLES ............................................................................................................ xii LIST OF FIGURES ......................................................................................................... xiv CHAPTER I. INTRODUCTION ................................................................................................1

References ....................................................................................................7

II. LITERATURE REVIEW .....................................................................................9

Pre-Arrival Risks and Needs: A Complex Picture of Too Little, Too Much .................................................................................................9 Pre-Arrival Nutrition Concerns: Refugees ...................................................9 Pre-Arrival Concerns: Central America .....................................................12 Nutritional Behaviors and Risks Post-Arrival ...........................................13 Youth Acculturation and Generational Differences ..................................14 Health Access, Needs, and Risks Post-Arrival ..........................................16 Considerations and Suggestions for Research with Newcomers ...............17 Literature Summary ...................................................................................18 Significance................................................................................................19 References ..................................................................................................22

III. EXAMINATION OF THE NUTRITION CONCERNS, INTERESTS AND NEEDS WITH NEWLY ARRIVED CAREGIVERS DURING A NUTRITION EDUCATION SESSION ...................................31

Abstract ......................................................................................................31 Introduction ................................................................................................32 Methods......................................................................................................35

Study Design ..................................................................................35 Site Description .............................................................................35 Family Day Description .................................................................36 Confidentiality, Translation, and Interpretation Services .............37 Nutrition Education Sessions .........................................................38 Obtaining Consent ........................................................................38 Data Collection .............................................................................39

 

x

Data Analysis .................................................................................39 Results ........................................................................................................39 Discussion ..................................................................................................42 References ..................................................................................................49

IV. MOVING LESS, NEW FOODS, AND GAINING WEIGHT: PERCEPTIONS, KNOWLEDGE, CONCERNS, AND INTERESTS FROM FOCUS GROUPS WITH NEWCOMER YOUTH ........................................................................................................55

Abstract ......................................................................................................55 Introduction ................................................................................................56 Methods......................................................................................................59

Study Design ..................................................................................59 Site Description .............................................................................60 Recruitment and Inclusion Criteria ...............................................61 Confidentiality, Translation, and Interpretation Services ..............61 Facilitation Group Sessions ...........................................................62 Data Collection and Analysis.........................................................63

Results ........................................................................................................63 Discussion ..................................................................................................67 References ..................................................................................................74

V. NUTRITION AND PHYSICAL ACTIVITY CHANGES, PERCEPTIONS, CONCERNS AND INTERESTS WITH A DIVERSE GROUP OF NEWCOMER YOUTH ..........................................79

Abstract ......................................................................................................79 Introduction ................................................................................................80 Methods......................................................................................................84

Study Design ..................................................................................84 Study Development ........................................................................84 Site Description .............................................................................85 Recruitment and Inclusion Criteria ................................................86 Confidentiality, Translation, and Interpretation Services ..............86 Survey Data Collection ..................................................................88 Anthropometric Measurements ......................................................89 Quantitative Data Analysis ............................................................89 Qualitative Survey Data Analysis ..................................................92

Results ........................................................................................................92 Discussion ................................................................................................118 References ................................................................................................130

 

xi

VI. EPILOGUE .......................................................................................................136

Future Work .............................................................................................139

APPENDIX A. LET’S TALK ABOUT FOOD PARENT GROUP GUIDE .................142 APPENDIX B. NUTRITION GUIDELINES: PROMOTING YOUR FAMILY’S HEALTH AND REDUCING DISEASE RISK ..........143 APPENDIX C. STUDY FLYER....................................................................................144 APPENDIX D. CAREGIVER CONSENT SCRIPT ......................................................146 APPENDIX E. ADOLESCENT GROUP DISCUSSION GUIDE ................................147 APPENDIX F. ADOLESCENT STUDY FLYER ........................................................149 APPENDIX G. PARENT CONSENT FORM ...............................................................151 APPENDIX H. ADOLESCENT ASSENT FORM ........................................................154 APPENDIX I. ADOLESCENT SURVEY ...................................................................157 APPENDIX J. SURVEY VARIABLES .......................................................................166

 

xii

LIST OF TABLES

Page

Table 1.1. Nutritional Markers from the World Health Organizations Nutrition Landscape Information System ..................................................................3 Table 3.1. Demographic Information of Newcomer Caregivers (N=38) .......................40 Table 3.2. Newcomer Caregiver’s Interest in Nutrition Education Topics by Language Group/Session .........................................................................41 Table 3.3. Nutrition and Health Concerns of Newcomer Parents ..................................42

Table 4.1. Adolescent Group Demographics by Session Type......................................64 Table 4.2. Adolescent Health Themes ...........................................................................64 Table 4.3. Adolescent Diet Themes ...............................................................................66 Table 4.4. Adolescent Physical Activity Themes ..........................................................67 Table 5.1. Dietary Acculturation Score Calculation ......................................................90 Table 5.2. Newcomer Youth Demographics (N=67) .....................................................93 Table 5.3. Household Characteristics ............................................................................95 Table 5.4. BMI Data (n=54) ..........................................................................................96 Table 5.5. BMI Data by Geographic Region .................................................................97 Table 5.6. Perceptions of Diet and Physical Activity Pre-/Post-Arrival to the U.S. ...........................................................................................................99 Table 5.7. Paired Samples t-tests Comparison of Food Patterns: Pre- and Post- U.S. Arrival .............................................................................................100 Table 5.8. Dietary Acculturation (Traditional and American) and Perceptions of Food (Access, Taste) ..........................................................................101

 

xiii

Table 5.9. Dietary Acculturation Scores by Region, Gender, English Use, and BMI (n=60) .............................................................................................102 Table 5.10. ANOVA Results: Sociodemographic Characteristics vs. Dietary Acculturation Scores .............................................................................103 Table 5.11. Sociodemographic Characteristics vs. Mean Dietary Acculturation Scores ......................................................................................................104 Table 5.12. Food Selection, Preparation, and Home Food Environment ......................105 Table 5.13. Influencing Food Choices ...........................................................................106 Table 5.14. ANOVA Results: Influencing Factors on Dietary Choices vs. Dietary Acculturation Scores ................................................................107 Table 5.15. Fischer’s Exact Test Results: Sociodemographic Variables vs. Influencing Factors on Food Choices ......................................................109 Table 5.16. Health, Diet, Weight Interests, Attitudes, Knowledge, Concerns ..............110 Table 5.17. Fischer’s Exact Test Results: Sociodemographic Variables vs. Health Literacy, Concerns and Perceptions, Nutrition, and Physical Activity Needs and Interests .....................................................112 Table 5.18. ANOVA Results: Significant Differences by Geographic Region .............113 Table 5.19. Open-ended Survey Question Data: Physical Activity ...............................115 Table 5.20. Open-ended Survey Question Data: Nutrition and Health ........................116 Table 5.21. Open-ended Survey Question Data: Important Foods (Daily, Cultural) .................................................................................................117 Table 5.22. Open-ended Question Survey Data: General Health/Nutrition Education Interest (Request(s) for More Information) ..........................118

 

xiv

LIST OF FIGURES

Page

Figure 5.1. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12–17 ..........................................................................................................96 Figure 5.2. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12-17 by Gender .........................................................................................97 Figure 5.3. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12-17 by Geographic Region ......................................................................98 Figure 5.4. Distribution of Dietary Acculturation Scores of Newcomer Youth Ages 12-17 ................................................................................................103

1

 

CHAPTER I

INTRODUCTION

In a report by the U.S. Census Bureau, it has been projected that by 2020 over

half of the children in America will be of an ethnic minority.1 By 2060 the total minority

population will reach 56% (it was 38% in 2014), with one in five individuals expected to

be foreign born.1 The U.S. population will likely grow from 296 million in 2005 to 438

million in 2050 with 82% of that growth from immigrants and their U.S.-born children.2

The top immigration categories include family sponsorship, employment, and

refuge/asylum (in order of decreasing frequency). The largest immigrant groups are

arriving from Mexico, China, India, and the Philippines (2013, by decreasing

frequency).3 The Hispanic population is the fastest growing as well as the “largest

minority” group.1,2 The majority (in 2013) came from Mexico, Dominican Republic,

Cuba, Columbia, and El Salvador (by decreasing frequency).3 In addition, many refugees

(most coming from Africa, Southeast Asia, and the Middle East) will add to the changes

in America’s population.

Of incoming groups, refugees make up the smallest proportion; however, the U.S.

receives the largest share (and majority) of resettled refugees. Since the United Nations

Refugee Convention in 1951, a refugee has been defined as an individual with

a well-founded fear of being persecuted for reasons of race, religion, nationality, membership of a particular social group or political opinion, is outside the country

2

 

of his nationality, who is unable to, or owing to such fear, is unwilling to avail himself of the protection of that country.4

To obtain refugee status an individual is identified by the United Nations High

Commissioner for Refugees (UNCHR). After identification a refugee may (a) return

home, (b) integrate into a neighboring host country, or (c) face resettlement into a third

country.4 It is this third category for which the U.S. receives the largest majority

worldwide; however, this is also the smallest fraction of displaced individuals and

refugees worldwide. Out of roughly 15 million refugees around the globe, only one

percent will be resettled into a new country and over half will end up in the U.S.5,6 In

2012, 74,835 refugees were identified by the UNCHR and the U.S. received 50,097.7 In

2012 the top countries of origin listed in decreasing frequency included Myanmar

(formerly known as Burma), Iraq, Bhutan, and Somalia.7 Resettlement to a country like

the U.S. is based on legal and/or physical protection needs, lack of alternatives, violence

or torture, women and girls at risk, medical needs, family reunification, and children and

adolescents at risk.7

Refugees resettled in the U.S. are prioritized and processed through the U.S.

Refugee Admissions Program and are connected with local resettlement agencies.8

Resettled refugees are afforded the same rights and services as citizens.6 U.S.

Resettlement reached an all-time high in 1980 (207,116) and low after September 11th in

2002 (27,100).9 Factors influencing refugee health are complex and may include

conditions and risks from both the country of origin and host country (camp).10 Refugees

3

 

often face unmanaged acute and chronic conditions, micronutrient deficiencies as well as

mental health needs.10

Pre-migration nutrition and health concerns, culture, health literacy, amongst

other factors vary widely between incoming groups, making health promotion and the

provision of health and social services with newcomers complex. Data from the World

Health Organization’s Nutrition Landscape Information System (NLiS) demonstrates a

few examples of the diversity of child and maternal nutrition concerns from countries

from which the U.S. receives large groups of refugees or immigrants.12 See Table 1.1.

Table 1.1

Nutritional Markers from the World Health Organizations Nutrition Landscape

Information System

%

< 5yrs underwt

% < 5yrs

ov/ob

% women ≥ BMI

25kg/m2

(ov/ob)

% of women exclusively

breastfeeding (1st 6m)

% Anemia < 5 yrs (Hb <110 g/L)

% Population below minimum level of dietary energy intake

Myanmar 22.6% 2.6% n/a 11% n/a 19.7%

Iraq 8.5% 11.% 69.6% 12.8% n/a 26.0%

Bhutan 12.8% 7.6% n/a 14% 80.6% n/a

Somalia 32.8% 4.7% n/a 6.3% n/a 66.3%

Mexico 2.8% 9% 71.9% 12.3% 23.7% n/a

Dominican Republic

4% 7.6% 38.3% 9.4% n/a 15.4%

El Salvador 6.6% 5.7% 57.2% 48% 19.8% 12.3%

4

 

For example, although individuals from El Salvador and Mexico could be

grouped together (both from Central America), 12.3% of women exclusively breastfeed

the first six months in Mexico in comparison to 48% in El Salvador. Nearly 81% (80.6%)

of children under five years of age have been found to be anemic in Bhutan in

comparison to 19.8% in El Salvador. In Somalia, over 66.3% of the population does not

meet daily energy requirements, and 32.8% of children under five years of age have

experienced wasting (below 2 standard deviations from median weight for height)11 in

comparison with 12.3% and 1.6%, respectively, in El Salvador. Over vs. under nutrition

risks vary strongly between countries of origin; moreover, variances also exist in health,

cultural food practices, and diet, as well as health beliefs and health literacy.

To alleviate some initial burden for refugees, they will receive services (although

limited in length, approximately three months initially; e.g., SNAP, Medicaid, finances

for housing, assigned a caseworker, social orientation) to help settle into their new lives

in the U.S. This is in stark contrast to immigrants who must adjust and navigate their new

home independently and for whom there are far less social and health services available.8

While refugees often have traumatic pre-resettlement experiences and have fled conflict

and/or resided in refugee camps (frequently leading to a lack of nutrition and health

resources pre-migration), immigrants will face common post-migration cultural,

language, and socioeconomic (lack of financial resources and/or education) barriers

heightening their risk.

Most of these incoming refugees and immigrants will relocate to a select ten U.S.

states. Of these states, North Carolina has ranked in the top ten in 2012 for refugee

5

 

resettlement and receives high numbers of immigrants annually.9 In 2013, North Carolina

was home to 749,426 immigrants with 31.9% naturalized U.S. citizens with high numbers

of Asian and Latin American immigrant populations.10 There were approximately

350,000 unauthorized immigrants in North Carolina in 2013.10 In addition, 2,110

refugees arrived in 2012 with most initially resettling in Charlotte, Durham, Greensboro,

High Point, New Bern, and Raleigh.12 The largest refugee populations in North Carolina

include the following countries of origin: Myanmar, Bhutan, Iraq, Cuba, Eritrea,

Democratic Republic of the Congo, and the Sudan.12

Immigration rates in North Carolina and the U.S. remain relatively stable as

global conflicts continue and individuals seek economic opportunity. Despite annual

resettlement and migration to the U.S. and increases in diversity, newcomer health and

nutrition research and resources are limited. This is of particular importance as newcomer

populations have demonstrated higher risks for nutrition concerns and health disparities.

Research regarding the unique health and nutrition needs, barriers, knowledge, and

attitudes of newcomer populations is lacking, likely due to the complex nature of

accessing and intervening (i.e., language and cultural barriers) with newcomer

populations. Moreover, improved health within these populations is a national priority

based on guidelines such as Healthy People 2020, which focus on eliminating health

disparities and ensuring improved health for all people.13

The goal of this research is to examine the nutrition and health perceptions,

behaviors knowledge, and interests of newcomer youth and families (residing in the U.S.

for no more than one year). Improving knowledge of the changes newcomers have

6

 

experienced, their perceptions, knowledge, and interests will serve to better guide future

services, interventions, and resources to reduce disparities and promote equity of health

for all Americans.

7

 

References

1. Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Population Estimates and Projections. Retrieved from http://www.census.gov/content/dam/Census/library/publications/2015/demo/ p25-1143.pdf

2. Passel, J. S., & Cohn, D. (2008). U.S. Population Projections: 2005-2050. Executive Summary. Pew Research Center. Retrieved from http://www.pewsocialtrends.org/ 2008/02/11/us-population-projections-2005-2050/

3. Monger, R., & Yankay, J. (2014, May). Annual Flow Report 2013: US Lawful Permanent Residents. Retrieved from http://www.dhs.gov/publication/us-lawful-permanent-residents-2013

4. Office of the United Nations High Commissioner for Refugees. (2016). Refugees: Flowing across borders. Retrieved from http://www.unhcr.org/pages/ 49c3646c125.html

5. U.S. Department of State. (n.d.). Refugee admissions. Retrieved from https://www.state.gov/j/prm/ra/index.htm

6. Office of the United Nations High Commissioner for Refugees. (2016). Resettlement: A new beginning in a third country. Retrieved from http://www.unhcr.org/pages/4a16b1676.html

7. Office of the United Nations High Commissioner for Refugees. (2014). The UNCHR Resettlement Statistical Report 2014. Retrieved from http://www.unhcr.org/ 52693bd09.html

8. Refugee Council USA. (n.d.). The US Resettlement Program in North Carolina. Retrieved from http://www.rcusa.org/uploads/pdfs/WRD-2014/North-Carolina.pdf

9. Martin, D. C., & Yankay, J. E. (2013). Annual Flow Report 2013: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_ 2013.pdf

10. Martin, D. C., & Yankay, J. E. (2012). Annual Flow Report 2012: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics.

8

 

Retrieved from https://www.dhs.gov/sites/default/files/publications/ ois_rfa_fr_2012.pdf

11. UNICEF. (n.d.). Nutrition: Definitions of the indicators. Retrieved from http://www.unicef.org/infobycountry/stats_popup2.html

12. American Immigration Council. (2013). New Americans in North Carolina: The political and economic power of immigrants, Latinos, and Asians in the Tar Heel State. Retrieved from http://www.immigrationpolicy.org/sites/default/files/docs/ new_americans_in_north_carolina_2015.pdf

13. Healthy People 2020. (2014). Disparities. Retrieved from http://www.healthypeople.gov/2020/about/DisparitiesAbout.aspx

9

 

CHAPTER II

LITERATURE REVIEW

Pre-Arrival Risks and Needs: A Complex Picture of Too Little, Too Much

Immigrants and refugees arrive to the U.S. with a wide range of health and

nutrition needs relating to the diversity of their pre-arrival experiences and environments.

Research with newcomers should include pre-migration conditions to provide context to

current needs, behaviors, and perceptions. Access to resources (e.g., food and water,

healthcare), experiences (e.g., war, poverty, violence), socioeconomic status and prior

education, culture, ethnicity and/or tribal affiliations, and religion can strongly influence

behaviors, perceptions, and needs upon arrival to the U.S. Moreover, the differences in

factors leading to migration to the U.S. (e.g., choice of an immigrant vs. refugee fleeing

persecution, active war) must also be taken into the context of needs post-arrival. The

literature reviewed in the following sections will focus on regions of the world and

populations that provide high numbers of immigrants and/or refugees annually (e.g.,

Central America immigrants and refugees from Middle East, Southeast Asia, and Africa).

Pre-Arrival Nutrition Concerns: Refugees

Many refugees arrive from regions in which women and children are vulnerable

for undernutrition, particularly in developing countries where rates of poverty and

conflict are high.1 Food insecurity, micronutrient deficiencies, communicable diseases,

poor child feeding practices, and lack of knowledge are common risk factors. Non-

10

 

exclusive breastfeeding (for the first 6 months), risky complementary-feeding practices,

and poor maternal nutrient status further exacerbate these risks.1,2 Displaced individuals

are at greater risk for poor feeding practices and micronutrient deficiencies due to

separation from protective social and economic environments as well as increased

poverty and food insecurity.1 Child malnutrition is highest in Southern Asia (30%),

Southeast Asia (16%), and Western, Eastern, and Middle Africa (20%, 19%, and 16%,

respectively) and it should also be noted that these regions have produced some of the

highest refugee populations resettling in the U.S. including the individuals from Bhutan,

Myanmar, and Somalia.3

Data collected through the Nutritional Landscape Assessment provided by WHO

indicates alarming rates of malnutrition (underweight, stunting, and wasting) in children

under five and below minimal dietary energy consumption from Nepal, Somalia, and

Myanmar.4-6 Additionally, micronutrient deficiencies and low exclusive breastfeeding

rates (for the first 6 months) have been reported in Myanmar and Somalia. Conversely,

Iraqi refugees demonstrate conditions associated with westernized nations with

overweight and obesity being major risk factors.7

Indicators of malnourishment such as stunting, underweight, and wasting are

prevalent experiences of many refugees before displacement to a nearby host country.

Upon arrival in the host country (or camp), rations and food assistance is often

inadequate in total energy, protein, and micronutrients. Research in camp settings

frequently focuses on women and children, especially children under five years of age, as

they are the most sensitive to health and nutritional conditions and are easily comparable

11

 

to growth and development standards.8 Malnourishment (stunting, underweight, and

wasting) has been observed in camps in both Southeast Asia and Africa, especially for

children between 3–6 months and 24 months and children under five years of age.8-12

Micronutrient deficiencies in Vitamin A, iron, and/or anemia are commonly observed in

Southeast Asia as well as African camp settings.10,11,13,14 Less than minimal energy and

protein requirements have also been reported in camp settings.8-11,13 Malnourishment and

undernourishment (stunting) have been observed simultaneously, with increased rates of

overweight and obesity in a long-term camp with Western Sahara refugees.12 Not all

regions share the same concerns.

For example, Iraqi refugees (n=18,990) screened from camps in Jordan en route to

the U.S. demonstrated more westernized issues with elevated rates of obesity, diabetes

mellitus, and hypertension.15 In another study in Lebanon, 47.9% of Iraqi refugees were

diagnosed with a chronic condition.16 Further complicating matters are also the location

Iraqi refugees initially resettled (e.g., Lebanon, Jordan, or Syria). For example, stark

differences in food security, malnutrition (under-nutrition), food aid, and hunger have

been found between conditions in Jordan vs. Syria.17 For Iraqis who reside in Lebanon,

food insecurity with hunger was found to be 44.4%, vs. Syria and Jordan (19.7–21.5%),

and food insecurity was found to significantly increase over time for Iraqi refugees in

Lebanon.16,17 For all Iraqis, food insecurity is associated with lack of access, diversity,

and quality in the diet.16,17

12

 

Pre-Arrival Concerns: Central America

Central American immigrants’ nutritional concerns overlap with Iraqis and follow

more modern, westernized issues due to the rapid globalization and modernization of

lifestyles and diet. Overweight and obesity are concerns with Mexican and El Salvadoran

populations prior to arriving to the U.S.18-20 Advertising for modern convenience foods in

El Salvador and high rates of snacking, particularly junk food snacks (soda, salty, sweet

snacks) and decreased fruit and vegetable consumption in Mexico has been reported

leading to a focus on overweight, obesity, and chronic disease (vs. previous concerns of

undernutrition).18-22 For example, between the 1980s and 1990s soda consumption

increased 37.2% in Mexico and the increases in refined carbohydrates and fat also

correlated with increases in chronic disease, weight gain, and obesity.20 In addition to

these modern dietary concerns, anemia and zinc deficiency (associated with stunting) are

still prevalent in many Central American countries (El Salvador, Honduras) and food

insecurity has also been identified (e.g., 64.8% households in El Salvador experience low

food security) along with less quality and diversity in the diet.23-26

In summary, research from Central America reports nutrition concerns of more

westernized countries as globalization and modernization of lifestyles and diet has

impacted these regions. Nutrition and health condition(s) of refugees from the Middle

East also follow westernized concerns comparable to Central American immigrants and

include many diet-related chronic diseases. In contrast, research reviewing African and

Southeast Asian refugees prior to resettlement (country of origin and camps) include

acute conditions of malnourishment (stunting, wasting, and underweight) and

13

 

deficiencies in quantity and quality of the diet. This variety of pre-migration nutritional

concerns increases the complexity in addressing health concerns within newcomer

populations.

Nutritional Behaviors and Risks Post-Arrival

Arrival to the U.S. presents a multitude of nutritional risks, barriers, and needs.

Access to cultural foods has been perceived as sufficient as individuals resettle or migrate

to areas with high numbers of immigrants and refugees (although cost may still be a

barrier).27-30 Food insecurity—lack of quantity and/or quality in the diet—is prevalent in

newcomer populations regardless of the ethnic group studied, location of resettlement, or

tool utilized.31-39 Contributing factors include limited time in the U.S., low acculturation

and language proficiency, poverty, low education, and difficulty navigating (identifying

foods, shopping process, cooking) the food system.31-34,38,40,41 Food insecurity has been

associated with increased BMI, decreased glycemic control, and has been observed for

multiple decades post-resettlement.34,40-43 Increased consumption of fast food,

convenience foods, and sugar sweetened beverages (SSB) has been reported across

multiple groups.27,29,44-50 Large generational disparities in dietary acculturation is

regularly reported and frequently results in family tension.27,29,44-47,51-55 A paradox

appears to be occurring as older generations attempt to maintain cultural foods; yet,

dietary acculturation continues (SSB and convenience foods).

In addition to dietary practices, knowledge and perceptions have been assessed.

Basic concepts (e.g., sugar and fat are poor are unhealthy, fruits and vegetables are

healthy) has been reported however, the impact of diet and excess weight on adverse

14

 

health outcomes faces a variety of barriers including: culture, religion or lack of nutrition

and health knowlege.45,53,56-60 Low physical activity (PA) levels and barriers or

misconceptions regarding PA are consistently reported as well as increasing trends of

weight gain and development of chronic conditions.27,30,44-47,58,61-65 In summary, a

multitude of risks exist for health related behaviors regarding diet and exercise upon

resettlement.

Youth Acculturation and Generational Differences

As previously cited, generational differences in dietary acculturation occurs with

youth accepting Western foods at faster rates. Newcomer youth are quickly exposed to

Western foods as they attend school. School offers many new foods—often convenience

foods—but also milk and other sources of dairy. Dietary acculturation in Asian and

Latino newcomer youth appears to have both positive and negative implications.

Improved nutrient status with adoption of some foods (i.e., calcium found in dairy

products) has been associated with increased acculturation; however, increases in fat

consumption, total calories, increases in BMI. and adverse effects on blood pressure has

also been reported.61-64,66 Less acculturated newcomer youth report higher consumption

of fruits and vegetables and diet quality.67-69 Not all groups acculturate at equal rates or

with equal outcomes.69-71

In a study by Allen et al., Latino and Asian youth were compared over several

generations. Asian youth maintained health behaviors or improved regarding diet quality

and physical activity, whereas Latino youth showed decreased diet quality over time.69 In

a study by Arcan et al., Somali, Hispanic, Hmong, and white adolescents were compared

15

 

and shared diet trends low in fruit, vegetables and dairy but high fast food consumption,

with Hispanic and Somali teens consuming the most fast food.71 Time, taste, and

convenience have been described as influencing factors in increasing consumption of fast

food and convenience foods in a study with Mexican, Cambodian, Sudanese, and

Somalian adolescents.53 In another study, Mexican Americans completely acculturated to

a Western diet, losing all components of their traditional diet within one generation.48

These studies support findings from studies with caregivers cited previously, in which

parents report their children request and desire Western foods, but also indicate

acculturation is complex and may vary distinctly between ethnic groups and may result in

positive and negative dietary changes.

Adolescents play a more active role in shopping and preparing foods for the

family, and have more independence choosing or preparing their own foods, with

newcomer youth reporting more participation in food selection and preparation.47,64,72,73

Additionally, the role of adolescent newcomers as cultural brokers may increase their

influence on the family diet.74 Different cultures report differences in the power

adolescents hold, with mixed influence reported in African homes and less influence in

some Asian cultures.45,68,74 Adolescents frequently demonstrate heightened sensitivity to

peer pressure, social expectations, and body image, and these trends are no different for

newcomer youth. Studies with African, Southeast Asian, and Hispanic youth all report

attempts to modify their diet or increase physical activity in order to control their weight

or “look/feel good.”47,67,71,72,74,75 Dieting in youth may occur in contrast to generational

differences in perception of weight with parents reporting attempts to increase children’s

16

 

weight, while youth report resistance.45,74 Many adolescents report family members with

chronic conditions, especially diabetes in African and Southeast Asian groups, however,

weight, is rarely associated as a risk factor (sugar is most commonly identified and

associated with diabetes).

In summary, dietary acculturation occurs rapidly in youth, varies between ethnic

groups, and may result in healthful and/or risky dietary choices, and if not improved will

likely lead to adverse health outcomes. Newcomer adolescents play a role in shopping

and preparing food and also demonstrate body image concerns as well as reports of

dieting or increased activity to modify body weight. Literature regarding attitudes,

knowledge, perceptions, and interests of newcomer adolescents is limited, despite the

potential health and nutrition risks associated with acculturation as “newly” adopted

foods are often convenience and fast foods.

Health Access, Needs, and Risks Post-Arrival

In addition to reported dietary and PA changes and concerns, newcomers

experience health disparities common to other minority, low income groups. These

include diet-related chronic conditions (diabetes, hypertension, increased BMI, dental

concerns) as well as health care access barriers (e.g., transportation, finances,

insurance).60,70,76-83 Pediatric overweight and obesity (2–17 years) has been found to

rapidly increase (17.3% to 36.4%, doubling in 3 years) in refugee children and youth with

the most rapid increases during the first year.78 Resettled refugees and immigrants face

additional issues including limited or non-existent skills to navigate health care systems

(i.e., making appointments, filling prescriptions, paperwork), language, literacy, and

17

 

cultural barriers, as well as mental health disorders including post-traumatic stress

disorder (PTSD) which further complicates achievement of health upon

resettlement.30,70,76,77 Other risks including limited health care access, difficulties

navigating healthcare in combination with nutritional risks (e.g., food insecurity,

difficulties navigating the food environment), and reductions in physical activity in

combination with cultural and language barriers further increase the vulnerability of

newcomer populations. Long-term, the health of newcomers is highly at risk for poor

outcomes, and achieving health equity is unlikely.

Considerations and Suggestions for Research with Newcomers

Large barriers exist in the design and implementation of research with Newcomer

populations due to their unique experiences, vulnerability, language, and cultural

barriers.84 Pre-migration (camp and/or host country) conditions further complicate health

upon resettlement and potentially increase vulnerability and disparities shared with other

marginalized, yet more established minority groups. Specific considerations regarding

methodology outlined in a paper by Ogilvie et al. highlight the complexities in sampling

(recruitment) as well as translation and interpretation.84 It is suggested that researchers

collaborate with trusted organizations serving refugees, are diligent to maintain cultural

competency and sensitivity, and are aware of the complex methodological considerations

in working with newcomers in order to access groups and collect quality data.

Other methodological considerations included are the approach with which an

assessment is conducted. Work by Palermo et al., as well as Lapping et al., suggests that

the context with which an assessment is framed (capacity focused vs. deficit/needs

18

 

oriented) will obtain different results—not necessarily conflicting results, but different

information.85,86 It may be important, based on these findings, to consider how questions

are framed. Edberg et al. suggest that when working with newcomers evaluating (a)

migration experience, (b) social adjustment, (c) socio-economic status (SES), (d) social

support, (e) neighborhood characteristics, (f) health status, (g) health knowledge and

practices, (h) access to care, and (i) perceived discrimination as health outcomes are

impacted by a complex array of factors.87

In summary, the design and implementation of research with newcomers,

particularly for refugees is complicated. Pre-migration experiences, methodological

barriers, and language and cultural barriers, as well as the large array of social and

environmental factors (often interrelated) driving health disparities must be considered.

Literature Summary

There are many complexities and barriers to accessing and intervening with

newcomer populations. Research with newcomers is limited; however, health and dietary

concerns have been reported. Pre-migration concerns include both acute and chronic

health and dietary needs, variable by country of origin and migration experiences (e.g.,

nutritional deficiency vs. excess). Pre-migration concerns include micronutrient and total

energy/protein deficiencies, food insecurity, physical and psychological effects of trauma

and violence, unmanaged or untreated health conditions, and increased exposure to

western diet and related conditions due to globalization of the food market. Post-

resettlement concerns include food insecurity, difficulty navigating food systems and

products, dietary acculturation and associated chronic conditions (e.g., obesity, diabetes),

19

 

dental and psychological needs, and barriers to accessing and receiving quality medical

care, as well as large generational variances in dietary acculturation. Risks,

vulnerabilities, and poor health outcomes have been observed in several groups.

Many major populations resettling in the U.S. remain understudied, including

populations from Bhutan, Myanmar (Burma), and Iraq, as well as a variety of African

nations (e.g., Eritrea, Ethiopia, Sudan, Somalia) and Central American countries (e.g., El

Salvador, Honduras) despite strong evidence of disparities and risks for these groups. The

perceptions, knowledge, needs and interests of many of these groups remain unknown.

Moreover, the perceptions, knowledge, needs, and interests of youth from these groups is

very limited or non-existent (e.g., Iraqi, Burmese, Honduran, and El Salvadoran youth).

Significance

The U.S. receives more refugees for resettlement than all other countries that

partner with the United Nations worldwide combined. Commitment to refugee

resettlement has not been matched with improved knowledge or resource development,

despite national priorities for reducing disparities and obtaining health equity for all

Americans. Trends of immigration from Central America continue and these immigrants

have helped to grow the Latino population in the U.S. to the largest and most rapidly

growing of minority groups. The vulnerability of groups, demonstrated health disparities,

and lack of research requires improved data collection and health promotion within these

groups. In addition, the increasing diversity of the U.S. further supports increasing and

improving research conducted with newcomers to meet the needs of the current

population in support of national goals relating to health equity for all people.

20

 

In light of the diet and health risks for newcomer populations and the consistently

reported rapid process of dietary acculturation and diet and physical activity-related

chronic disease conditions (e.g., diabetes, obesity), it is important to further investigate

the process and influencing factors with which new foods are both introduced and chosen

(both healthful and unhealthful foods). It is also of equal importance to identify pre-

arrival food trends and physical activity levels in order to accurately identify changes or

“acculturation.” For example, pre-arrival diets and physical activity trends are rarely

evaluated; yet, to accurately identify change, it is necessary to have an informed picture

of the original diet and physical activity levels. In addition, few studies have extensively

identified factors that influence food choices in newcomer populations, particularly with

youth who have been reported to rapidly accept westernized diets and trends of reduced

physical activity and weight gain.

Many questions regarding dietary changes in newcomer groups remain

unanswered, and many groups remain understudied despite high migration numbers. The

influencing factors and process with which new foods are both introduced as well as

chosen has been poorly investigated. In addition to these gaps, generational differences

and the rapid dietary acculturation in youth has not been fully examined. The unique

experiences and changes that youth undergo (memories and experience of country of

origin and incorporation and introduction of Westernized foods and culture in the school

system) is not well understood. The motivating factors shaping diet and PA behaviors of

newcomer youth is unknown, despite evidence of rapid dietary acculturation, weight

concerns and dieting behaviors, and reductions in physical activity. Examining the role of

21

 

the adolescent in food choices (shopping) and preparation may position them to hold an

influential place in the dietary and physical activity of the household and provide insight

to support future intervention(s).

Lastly, in summary, immigration and refugee resettlement remains steady in the

U.S. Research is lacking, especially from specific countries of origin (e.g., Myanmar,

Iraq, El Salvador). Many populations (especially children and youth) demonstrate high

health and nutrition concerns pre-migration and upon resettlement. Rapid acculturation in

youth and diet-related chronic conditions in adults has been observed; however,

motivation, perceptions, attitudes, and interests have neither been well explored, nor has

the role of adolescents in influencing the diet and health of the home/family upon arrival

in the U.S. Research with newcomers is limited despite high numbers, reported

disparities, and vulnerabilities contrasting a national commitment to health equity.

Improving the knowledge of the changes, perceptions, knowledge, and interests of

newcomer youth and families may be used to guide future intervention to reduce

disparities frequently observed over time in newcomer (both immigrant and refugee)

groups.

22

 

References

1. Khan, Y., & Bhutta, A. Z. (2010). Nutritional deficiencies in the developing world: Current status and opportunity for intervention. Pediatric Clinics of North America, 57(6), 1409–1441. doi:10.1016/j.pcl.2010.09.016

2. World Health Organization. (2016). Health topics: Breastfeeding. Retrieved from http://www.who.int/topics/breastfeeding/en/

3. World Health Organization. (2016). Global health observatory: Underweight in children. Retrieved from http://www.who.int/gho/mdg/poverty_hunger/ underweight_text/en/

4. World Health Organization. (2016). NLiS country profile: Nepal. Retrieved from http://apps.who.int/nutrition/landscape/report.aspx?iso=npl

5. World Health Organization. (2016). NLiS country profile: Myanmar. Retrieved from http://apps.who.int/nutrition/landscape/report.aspx?iso=mmr

6. World Health Organization. (2016). NLiS country profile: Somalia. Retrieved from http://apps.who.int/nutrition/landscape/report.aspx?iso=som

7. World Health Organization. (2016). NLiS country profile: Iraq. Retrieved from http://apps.who.int/nutrition/landscape/report.aspx?iso=irq

8. Renzaho, A., & Renzaho, C. (2003). In the shadow of the volcanoes: The impact of intervention on the nutrition and health status of refugee children in Zaire two years on from the exodus. Nutrition & Dietetics, 60(2), 85–91. http://hdl.handle.net/10536/DRO/DU:30004115

9. Olwedo, M. A., Mworozi, E., Bachou, H., & Orach, C. G. (2008). Factors associated with malnutrition among children in internally displaced person’s camps, northern Uganda. African Health Sciences, 8(4), 244–252.

10. Banjong, O., Menefee, A., Sranacharoenpong, K., Chittchang, U., Eg-kantrong, P., Boonpraderm, A., & Tamachotipong, S. (2003). Dietary assessment of refugees living in camps: A case study of Mae La Camp, Thailand. Food and Nutrition Bulletin, 24(4), 360–367.

11. Kemmer, T. M., Bovill, M. E., Kongsomboon, W., Hansch, S. J., Geisler, K. L., Cheney, C., . . . Drewnowski, A. (2003). Iron deficiency is unacceptably high in refugee children from Burma. The Journal of Nutrition, 133(12), 4143–4149.

23

 

12. Grijalva-Eternod, C. S., Wells, J. C., Cortina-Borja, M., Salse-Ubach, N., Tondeur, M. C., Dolan, C., . . . Seal, A. J. (2012). The double burden of obesity and malnutrition in a protracted emergency setting: A cross-sectional study of Western Sahara refugees. PLoS Medicine, 9(10), e1001320. doi:10.1371/journal.pmed.1001320

13. Seal, A. J., Creeke, P. I., Mirghani, Z., Abdalla, F., McBurney, R. P., Pratt, L. S., . . . Marchand, E. (2005). Iron and vitamin A deficiency in long-term African refugees. The Journal of Nutrition, 135(4), 808–813.

14. Woodruff, B. A., Blanck, H. M., Slutsker, L., Cookson, S. T., Larson, M. K., Duffield, A., & Bhatia, R. (2006). Anaemia, iron status and vitamin A deficiency among adolescent refugees in Kenya and Nepal. Public Health Nutrition, 9(1), 26–34.

15. Yanni, E. A., Naoum, M., Odeh, N., Han, P., Coleman, M., & Burke, H. (2013). The health profile and chronic diseases comorbidities of US-bound Iraqi refugees screened by the International Organization for Migration in Jordan: 2007–2009. Journal of Immigrant and Minority Health, 15(1), 1–9. doi:10.1007/s10903-012-9578-6.

16. Ghattas, H., Sassine, A. J., Seyfert, K., Nord, M., & Sahyoun, N. R. (2014). Food insecurity among Iraqi refugees living in Lebanon, 10 years after the invasion of Iraq: Data from a household survey. British Journal of Nutrition, 112(1), 70–79. doi:10.1017/S0007114514000282

17. Doocy, S., Sirois, A., Anderson, J., Tileva, M., Biermann, E., Storey J. D., & Burnham, G. (2011). Food security and humanitarian assistance among displaced Iraqi populations in Jordan and Syria. Social Science & Medicine, 72(2), 273–282. doi:10.1016/j.socscimed.2010.10.023

18. Aburto, T. C., Cantoral, A., Hernández-Barrera, L., Carriquiry, A. L., & Rivera, J. A. (2015). Usual dietary energy density distribution is positively associated with excess body weight in Mexican children. The Journal of Nutrition, 145(7), 1524–1530. doi:10.3945/jn.114.206359

19. Jiménez-Aguilar, A., Gaona-Pineda, E.B., Mejía-Rodríguez, F., Gómez-Acosta, L.M., Méndez-Gómez Humarán, I., & Flores-Aldana, M. (2014). Consumption of fruits and vegetables and health status of Mexican children from the National Health and Nutrition Survey 2012. Salud Pública de México, 56(Suppl 2), s103–s112.

20. Rivera, J. A., Barquera, S., González-Cossío, T., Olaiz, G., & Sepúlveda, J. (2004). Nutrition transition in Mexico and in other Latin American countries. Nutrition Review, 62(7 Pt 2), S149–S157.

24

 

21. Amanzadeh, B., Sokal-Gutierrez, K., & Barker, J. C. An interpretive study of food, snack and beverage advertisements in rural and urban El Salvador. BMC Public Health, 15, 521. doi:10.1186/s12889-015-1836-9

22. Duffey, K. J., Rivera, J. A., & Popkin, B. M. (2014). Snacking is prevalent in Mexico. Journal of Nutrition, 144(11), 1843-1849. doi:10.3945/jn.114.198192

23. Mujica-Coopman, M. F., Brito, A., López de Romaña, D., Ríos-Castillo, I., Coris, H., & Olivares, M. (2015). Prevalence of Anemia in Latin America and the Caribbean. Food and Nutrition Bulletin, 36(2 Suppl), S119–S128.

24. Fuster, M., Houser, R. F., Messer, E., Palma de Fulladolsa, P., Deman, H., & Bermudez, O. I. (2013). Perceived access and actual intake of healthy diets among households in vulnerable Salvadoran communities. Journal of Nutrition Education and Behavior, 45(6), 713–717. doi:10.1016/j.jneb.2013.06.002

25. Cediel, G., Olivares, M., Brito, A., Cori, H., & López de Romaña, D. (2015). Zinc deficiency in Latin America and the Caribbean. Food and Nutrition Bulletin, 36(2 Suppl), S129–S138.

26. Martínez, A. D. (2013). Reconsidering acculturation in dietary change research among Latino immigrants: Challenging the preconditions of US migration. Ethnicity & Health, 18(2), 115–135. doi:10.1080/13557858.2012.698254

27. Willis, M. S., Buck, J. S. (2007). From Sudan to Nebraska: Dinka and Nuer refugee diet dilemmas. Journal of Nutrition Education and Behavior, 39(5), 273–280. doi:10.1016/j.jneb.2006.10.005

28. Pereira, C., Larder, N., & Somerset, S. (2010). Food acquisition habits in a group of African refugees recently settled in Australia. Health & Place, 16(5), 934–941. doi:10.1016/j.healthplace.2010.05.007

29. Patil, C. L., Hadley, C., & Nahayo, P. D. (2009). Unpacking dietary acculturation among new Americans: Results from formative research with African refugees. Journal of Immigrant and Minority Health, 11(5), 342–358. doi:10.1007/s10903-008-9120-z

30. Adekeye, O., Kimbrough, J., Obafemi, B., & Stack, R. (2014). Health literacy from the perspective of African immigrant youth and elderly: A PhotoVoice project. Journal of the Poor and Underserved, 25(4), 1730–1747. doi:10.1353/hpu.2014.0183

31. Hadley, C., Patil, C. L., & Nahayo, D. (2010). Difficulty in the food environment and the experience of food insecurity among refugees resettled in the United States. Ecology of Food and Nutrition, 49(5), 390–407. doi:10.1080/03670244.2010.507440

25

 

32. Hadley, C., Zodhiates, A., & Sellen, D. W. (2007). Acculturation, economics and food insecurity among refugees resettled in the USA: A case study of West African refugees. Public Health and Nutrition, 10(4), 405–412.

33. Hadley, C., & Sellen, D. (2006). Food insecurity and child hunger among recently resettled Liberian refugees and asylum seekers: A pilot study. Journal of Immigrant and Minority Health, 8(4), 369–375.

34. Dharod, J., Croom, J. E., & Sady, C. G. (2013). Food insecurity: Its relationship to dietary intake and body weight among Somali refugees women in the United States. Journal of Nutrition Education and Behavior, 45(1), 47–53. doi:10.1016/j.jneb.2012.03.006

35. Sharkey, J. R., Dean, W. R., & Nalty, C. C. (2013). Child hunger and the protective effects of Supplemental Nutrition Assistance Program (SNAP) and alternative food sources among Mexican-origin families in Texas border colonias. BMC Pediatrics, 13, 143. doi:10.1186/1471-2431-13-143

36. Quandt, S. A., Shoaf, J. I., Tapia, J., Hernández-Pelletier, M., Clark, H. M., & Arcury, T. A. (2006). Experiences of Latino immigrant families in North Carolina help explain elevated levels of food insecurity and hunger. Journal of Nutrition, 136(10), 2638–2644.

37. Munger, A. L., Lloyd, T. D., Speirs, K. E., Riera, K. C., & Grutzmacher S. K. (2015). More than just not enough: Experiences of food insecurity for Latino immigrants. Journal of Immigrant and Minority Health, 17(5), 1548–1556. doi:10.1007/s10903-014-0124-6

38. Iglesias-Rios, L., Bromberg, J. E., Moser, R. P., & Augustson, E. M. (2015). Food insecurity, cigarette smoking, and acculturation among Latinos: Data from NHANES 1999–2008. Journal of Immigrant and Minority Health, 17(2), 349–357. doi:10.1007/s10903-013-9957-7.

39. Anderson, L., Hadzibegovic, D. S., Moseley, J. M., & Sellen, D. W. (2014). Household food insecurity shows associations with food intake, social support utilization and dietary change among refugee adult caregivers resettled in the United States. Ecology of Food and Nutrition, 53(3), 312–332. doi:10.1080/03670244.2013.831762

40. Buscemi, J., Beech, B. M., & Relyea, G. (2011). Predictors of obesity in Latino children: Acculturation as a moderator of the relationship between food insecurity and body mass index percentile. Journal of Immigrant and Minority Health, 13(1), 149–154. doi:10.1007/s10903-009-9263-6

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41. Leung, C. W., Williams, D. R., & Villamor, E. (2012). Very low food security predicts obesity predominantly in California Hispanic men and women. Public Health Nutrition, 15(12), 2228–2236. doi:10.1017/S1368980012000857

42. Peterman, J. N., Wilde, P. E., Silka, L., Bermudez, O. I., & Rogers, B. L. (2013). Food insecurity among Cambodian refugee women two decades post resettlement. Journal of Immigrant and Minority Health, 15(2), 372–380. doi:10.1007/s10903-012-9704-5

43. Bawadi, H. A., Ammari, F., Abu-Jamous, D., Khader, Y. S., Bataineh, S., & Tayyem, R. F. (2012). Food insecurity is related to glycemic control deterioration in patients with type 2 diabetes. Clinical Nutrition, 31(2), 250–254. doi:10.1016/j.clnu.2011.09.014

44. Vue, W., Wolff, C., & Goto, K. (2011). Hmong food helps us remember who we are: Perspectives of food culture and health among Hmong women with young children. Journal of Nutrition Education and Behavior, 43(3), 199–204. doi:10.1016/j.jneb.2009.10.011

45. Wilson, A., & Renhazo, A. (2014). Intergenerational differences in acculturation experiences, food beliefs, and perceived health risks among refugees from the Horn of Africa in Melbourne, Australia. Public Health Nutrition, 18(1), 176–188. doi:10.1017/S1368980013003467

46. Rondinelli, A. J., Morris M. D., Rodwell T. C., Moser K.S., Paida P., Popper S.T., & Brouwer K. C. (2011). Under- and over-nutrition among refugees in San Diego County, California. Journal of Immigrant and Minority Health, 13(1), 161–168. doi:10.1007/s10903-010-9353-5

47. Franzen, L., & Smith, C. (2009). Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite, 52(1), 173–183. doi:10.1016/j.appet.2008.09.012

48. Batis, C., Hernandez-Barrera, L., Barquera, S., Rivera, J. A., & Popkin, B. M. (2011). Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. Journal of Nutrition, 141(10), 1898–1906. doi:10.3945/jn.111.141473

49. Santiago-Torres, M., Adams, A. K., Carrel, A. L., LaRowe, T. L., & Schoeller, D. A. Home food availability, parental dietary intake, and familial eating habits influence the diet quality of urban Hispanic children. Child Obesity, 10(5), 408–415. doi:10.1089/chi.2014.0051

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50. Beck, A.L., Tschann, J., Butte, N.F., Penilla, C., & Greenspan, L. C. (2014). Association of beverage consumption with obesity in Mexican American children. Public Health Nutrition, 17(2), 338–344. doi:10.1017/S1368980012005514

51. Garnweidner, L. M., Terragni, L., Pettersen, K. S., & Mosdol, A. (2012). Perceptions of the host country’s food culture among female immigrants from Africa and Asia: Aspects relevant for cultural sensitivity in nutrition communication. Journal of Nutrition Education and Behavior, 44(4), 335–342. doi:10.1016/j.jneb.2011.08.005

52. Peterman, J. N., Silka, L., Bermudez, O. I., Wilde, P. E., & Rogers, B. L. (2011). Acculturation, education, nutrition education, and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. Journal of the American Dietetic Association, 111(9), 1369–1374. doi:10.1016/j.jada.2011.06.005

53. Tiedje, K., Wieland, M. L., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2014). A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States. International Journal of Behavioral Nutrition and Physical Activity, 11, 63. doi:10.1186/1479-5868-11-63

54. Anderson, L. C., Mah, C. L., & Sellen, D. W. (2015). Eating well with Canada’s food guide? Authoritative knowledge about food and health among newcomer mothers. Appetite, 91, 357–365. doi:10.1016/j.appet.2015.04.063

55. Mannion, C. A., Raffin-Bouchal, S., & Henshaw, C. J. (2014). Navigating a strange and complex environment: Experiences of Sudanese refugee women using a new nutrition resource. International Journal of Women’s Health, 16(6), 411–422. doi:10.2147/IJWH.S56256

56. Barnes, D. M., & Almasy, N. (2005). Refugees’ perceptions of healthy behaviors. Journal of Immigrant Health, 7(3), 185–193.

57. Choi, S. E., Rush, E., & Henry, S. (2013). Health literacy in Korean immigrants at risk for type 2 diabetes. Journal of Immigrant Health, 15(3), 553–559. doi:10.1007/s10903-012-9672-9

58. Drummond, P., Mizan, A., Burgoyne, A., Wright, B. (2011). Knowledge of cardiovascular risk factors in west African refugee women living in western Australia. Journal of Immigrant Minority Health, 13(1), 140–148. doi:10.1007/s10903-010-9322-z

59. Flores, G., Maldonado, J., & Durán, P. (2012). Making tortillas without lard: Latino parents’ perspectives on healthy eating, physical activity, and weight-management

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strategies for overweight Latino children. Journal of the Academy of Nutrition and Dietetics, 112(1), 81–89. doi:10.1016/j.jada.2011.08.041

60. Fisher-Hoch, S. P., Vatcheva, K. P., Rahbar, M. H., & McCormick, J. B. (2015). Undiagnosed diabetes and pre-diabetes in health disparities. PLoS ONE, 10(7), e0133135. doi:10.1371/journal.pone.0133135

61. Mulasi-Pokhriyal, U., Smith, C., & Franzen-Castle, L. (2012). Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9–18 years. Public Health Nutrition, 15(1), 176–185. doi:10.1017/S1368980011001649

62. Hrboticky, N., & Krondl, M. (1984). Acculturation to Canadian foods by Chinese immigrant boys: Changes in the perceived flavor, health value and prestige of foods. Appetite, 5(2), 117–126. doi:10.1016/S0195-6663(84)80031-8

63. Smith, C., & Franzen-Castle, L. (2012). Dietary acculturation and body composition predict American Hmong children’s blood pressure. American Journal of Human Biology, 24(5), 666–674. doi:10.1002/ajhb.22295

64. Benbenek, M. M., & Garwick, A. W. (2012). Enablers and barriers to dietary practices contributing to bone health among early adolescent Somali girls living in Minnesota. Journal for Specialists in Pediatric Nursing, 17(3), 205–214. doi:10.1111/j.1744-6155.2012.00334.x

65. Wieland, M. L., Tiedje, K., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2015). Perspectives on physical activity among immigrants and refugees to a small urban community in Minnesota. Journal of Immigrant and Minority Health, 17, 263–275. doi:10.1007/s10903-013-9917-2

66. Franzen-Castle, L., & Smith, C. (2014). Environmental, personal, and behavioral influences on BMI and acculturation of second generation Hmong children. Maternal and Child Health Journal, 18(1), 73–89. doi:10.1007/s10995-013-1235-8

67. Diaz, H., Marshak, H. H., Montgomery, S., Rea, B., & Backman D. (2009). Acculturation and gender: Influence on healthy dietary outcomes for Latino adolescents in California. Journal of Nutrition Education and Behavior, 41(5), 319–326. doi:10.1016/j.jneb.2009.01.003

68. Liu, J. H., Chu, Y. H., Frongillo, E. A., & Probst, J. C. (2012). Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. Journal of Nutrition, 142(2), 298–305. doi:10.3945/jn.111.145516

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69. Allen, M. L., Elliott, M. N., Morales, L. S., Diamant, A. L., Hambarsoomian, K., & Schuster, M. A. (2007). Adolescent participation in preventive health behaviors, physical activity, and nutrition: Differences across immigrant generations for Asians and Latinos compared with Whites. American Journal of Public Health, 97(2), 337–343.

70. Morris, M. D., Popper, S. T., Rodwell, T. C., Brodine, S. K., & Brouwer, K. C. (2009). Healthcare barriers of refugees post-resettlement. Journal of Community Health, 34(6), 529–538. doi:10.1007/s10900-009-9175-3

71. Arcan, C., Larson, N., Bauer, K., Berge, J., Story, M., & Neumark-Sztainer, D. (2014). Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and white adolescents. Journal of the Academy of Nutrition and Dietetics, 114(3), 375–383. doi:10.1016/j.jand.2013.11.019

72. Stang, J., Kong, A., Story, M., Eisenberg, M. E., & Neumark-Sztainer, D. (2007). Food and weight-related patterns and behaviors of Hmong adolescents. Journal of the American Dietetic Association, 107(6), 936–941.

73. Story, M., & Harris, L. J. (1989). Food habits and dietary change of Southeast Asian refugee families living in the United States. Journal of the American Dietetic Association, 89(6), 800–803.

74. Kim, L. P., Harrison, G. G., Kagawa-Singer, M. (2007). Perceptions of diet and physical activity among California Hmong adults and youths. Preventing Chronic Disease, 4(4), A93.

75. Renzaho, A. M., McCabe, M., & Swinburn, B. (2012). Intergenerational differences in food, physical activity, and body size perceptions among African migrants. Qualitative Health Research, 22(6), 740–754. doi:10.1177/1049732311425051

76. Filippi, M. K., Faseru, B., Baird, M., Ndikum-Moffer, F., Greiner, K. A., & Daley, C. M. (2012). A pilot study of health priorities of Somalis living in Kansas City: Laying the groundwork for CBPR. Journal of Immigrant and Minority Health, 16(2), 314–320. doi:10.1007/s10903-012-9732-1

77. Renzaho, A. M. N., Bilal, P., & Marks, G.C. (2014). Obesity, type 2 diabetes, and high blood pressure amongst recently arrived Sudanese refugees in Queensland, Australia. Journal of Immigrant and Minority Health, 16(1), 86–94. doi:10.1007/s10903-013-9791-y

78. Heney, J., Dimock, C., Friedman, J., & Lewis, C. (2015). Pediatric refugees in Rhode Island: Increases in BMI percentile, overweight, and obesity following resettlement. Rhode Island Medical Journal, 98(1), 43–47.

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79. Rodriguez, C. J., Cai, J., Swett, K., González, H. M., Talavera, G. A., Wruck, L. M., . . . Daviglus, M. L. (2015). High cholesterol awareness, treatment, and control among Hispanic/Latinos: Results from the Hispanic Community Health Study/Study of Latinos. Journal of the American Heart Association, 4, e001867. doi:10.1161/JAHA.115.001867

80. Jen, K. L., Zhou, K., Arnetz, B., & Jamil, H. (2015). Pre- and post-displacement stressors and body weight development in Iraqi refugees in Michigan. Journal of Immigrant and Minority Health, 17(5), 1468–1475 doi:10.1007/s10903-014-0127-3

81. Taylor, E. M., Yanni, E. A., Pezzi, C., Guterbock, M., Rothney, E., Harton, E., . . . Burke, H. (2014). Physical and mental health status of Iraqi refugees resettled in the United States. Journal of Immigrant and Minority Health, 16(6), 1130–1137.

82. Centers for Disease Control and Prevention. (2010). Morbidity and Mortality Weekly Report: Health of Resettled Iraqi Refugees—San Diego County, California, October 2007–September 2009. Morbidity and Mortality Weekly Report, 59(49), 1614–1618.

83. Dharod, J. M. (2015). What changes upon resettlement: Understanding difference in pre- and post-resettlement dietary habits among South-Asian refugees. Ecology of Food and Nutrition, 54(3), 209–223. doi:10.1080/03670244.2014.964800

84. Ogilvie, L. D., Burgess-Pinto, E., & Caufield, C. (2008). Challenges and approaches to newcomer health research. Journal of Transcultural Nursing, 19(1), 64–73. doi:10.1177/1043659607309142

85. Palermo, C., Robinson, C., Robertson, K., & Hii, S. (2012). Approaches for prioritizing the nutritional needs of refugee communities. Australian Journal of Primary Health, 18(1), 11–16. doi:10.1071/PY11008

86. Lapping, K., Schroeder, D., Marsh, D., Albalak, R., & Jabarkhil, M. Z. (2002). Comparison of a positive deviant inquiry with a case control study to identify factors associated with nutritional status among Afghan refugee children in Pakistan. Food and Nutrition Bulletin, 23(4), 26–33. doi:10.1177/15648265020234S205

87. Edberg, M., Cleary, S., & Vyas, A. (2011). A trajectory model for understanding and assessing health disparities in immigrant/refugee communities. Journal of Immigrant and Minority Health, 13(3), 576–584. doi:10.1007/s10903-010-9337-5

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CHAPTER III

EXAMINATION OF THE NUTRITION CONCERNS, INTERESTS AND NEEDS

WITH NEWLY ARRIVED CAREGIVERS DURING A NUTRITION EDUCATION SESSION

Abstract

Introduction: In 2012, North Carolina ranked in the top ten for refugee resettlement.

New arrivals are understudied, yet at risk for food insecurity, nutrition-related health

conditions, and have limited skills navigating the local food environment. The objective

of this study was to examine the nutrition and health perceptions, interests, and needs for

newly-arrived caregivers.

Methods: Data were collected from parents after a nutrition education session provided

during family outreach at a school in North Carolina for newcomers. Participants (n=38)

included Spanish, Vietnamese, French, and Arabic speaking caregivers (most in U.S. ≤ 1

year). Facilitated discussions conducted via interpreters were recorded by handwritten

notes. Themes were identified using content analysis.

Results: Interest in nutrition education topics included nutrition education in their

community (n=31), information/assistance using food labels (n=30), tasting new healthy

American foods (n=30), diets to reduce risk of chronic disease (n=29), foods important

for children’s growth and development (n=26), and interest in a shopping companion to

assist navigation of American products and grocery stores (n=20). Independently initiated

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areas of concern included poor diet choices of their children, limited healthy options in

restaurants, and specific health concerns.

Conclusions: Results from this study demonstrate strong interest from a diverse group of

newly-arrived caregivers regarding specific nutrition education topics. This interest in

combination with their risk and vulnerability supports early provision of nutrition

education for new arrivals. Future research should evaluate the impact of early

interventions on food insecurity, diet quality, and chronic disease rates.

Introduction

In 2013, 990,553 individuals became lawful residents in the U.S.1 Leading

countries of birth included Mexico (14%), China (7.2%), and India (6.9%).1 In addition,

in 2013, 69,909 refugees entered the U.S. with top countries of origin including Iraq

(27.9%), Burma (23.3%), Bhutan (13.1%), and Somalia (10.9%).2 Individuals entering

under refugee status must fit within the specific criteria outlined by the Immigration and

Nationality Act 101(a)(42) and must be “unable or unwilling to return to his or her

country of nationality because of persecution or a well-founded fear of persecution on

account of race, religion, nationality, membership in a particular social group, or political

opinion.”3

Consistent levels of annual immigration rates (990,553 in 2013, 1,031,632 in

2012, and 1,062,040 in 2011) continue to impact the ethnic makeup of the U.S. which is

projected by the Census Bureau to rapidly change between 2014 and 2060.1,4 The

foreign-born population is estimated to grow by 85% between 2014 and 2060, and by

2060 one in five individuals will be foreign born.4 By 2044 whites will for the first time

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be in the minority and the U.S. will switch to a “U.S. minority-majority” nation.4 With

this rapid increase in population, the fastest growing ethnic minority groups include “two

or more races,” Asians and Hispanics, which are expected to grow 226%, 143%, and

115%, respectively.4 As the diversity of the U.S. continues to increase over the next few

decades, the health and nutrition needs of these groups must be examined in order to

support national, state, and local health priorities and polices (e.g., Healthy People) that

will address the health and nutrition needs of the current population while seeking to

reduce health disparities that are unequally distributed in minority groups. Unfortunately,

many immigrant, and especially refugee groups have not been well studied despite

demonstrated risks.

Arrival to the U.S. presents a multitude of nutritional risks, barriers, and needs.

Although access to cultural foods is often perceived as sufficient (although cost may still

be a barrier),5-8 food insecurity has been reported to be elevated in immigrant and refugee

populations. Food insecurity—the lack of adequate quantity and/or quality in the diet—is

prevalent in newcomer populations regardless of the ethnic group studied, location of

resettlement, or tool utilized (e.g., national average is 14% in contrast to newcomer

households which have been found as high as 53%, 67%, 85%, and even 96%).9-18

Contributing factors include limited time in the U.S., low acculturation and language

proficiency, poverty, low education, and difficulty navigating (identifying foods,

shopping process, cooking) the food system.10-13,17,19,20 Food insecurity has been

associated with increased BMI, decreased glycemic control, with levels remaining high

even multiple decades post-resettlement.13,19-22 In addition, dietary change occurs and

34

 

increased consumption of fast food, convenience foods, meat, and sugar-sweetened

beverages (SSBs) are consistently reported across various groups.6,8,23-29 Youth and

children are exposed to westernized foods during school and through WIC and their rapid

adoption of new foods and reduced consumption of traditional foods is frequently

reported and results in family tension.6,8,23-26,30-34

In addition to the potentially negative dietary changes, lifestyle changes and

health literacy have also been examined with newcomer populations (although this work

is limited). Basic concepts such as the need to maintain “balance” and the negative

effects of sugar, fat, and salt have been reported as well as an understanding that fruits

and vegetables support health, yet weight is rarely identified as a health risk (e.g.,

diabetes risk is strongly associated with sugar vs. weight and physical inactivity).24,32,35,39

In addition to negative dietary changes, physical activity is frequently reported to

decrease upon arrival to the U.S. with a multitude of barriers reported, as well as

increasing trends of weight gain and development of chronic conditions (e.g., diabetes,

hypertension).6,9,23-26,37,40-44

In summary, a multitude of nutrition and health risks exist for newcomers;

however, research with these groups remains limited and continued assessment is

warranted to examine the nutrition and health perceptions and interests of newcomers to

better support resources and/or interventions that reduce negative dietary and physical

activity changes upon arrival to the U.S. as well as chronic disease burden over time. The

objectives of this study were to (a) examine the dietary perceptions, behaviors, and/or

concerns of newcomer caregivers with upon arrival to the U.S., and (b) examine the

35

 

interests of newcomer caregivers regarding a variety of nutrition topics and/or

educational opportunities.

Methods

Study Design

Facilitated group discussions were conducted during a bi-annual Saturday

community outreach program at a school for newcomer youth in North Carolina in April

of 2015.i Questions were based on a guide that was content validated by experts (n=3) in

the field of immigrant and refugee nutrition and health and/or family focused nutrition

(see Appendix A). Questions targeted nutrition topics and concerns as well as preferences

for future intervention and educational activity interests. The study was approved by the

institutional review board at the University of North Carolina at Greensboro and the

Research Review Committee of the school district prior to any recruitment and/or data

collection. Informed consent was obtained prior to any data collection.

Site Description

The study was conducted at a school for newcomer youth in North Carolina that

provides a specialized environment for students during their first year in the U.S. North

Carolina ranked in the top ten in 2012 for refugee resettlement and receives high numbers

of immigrants annually.44 North Carolina was home to 749,426 immigrants in 2013 with

31.9% naturalized U.S. citizens consisting of high numbers of Asian and Latin American

immigrant populations.45 There were approximately 350,000 unauthorized immigrants in

North Carolina in 2013.45 Also, there were 2,110 refugees who arrived in North Carolina

                                                            i This description of the school is the wording required in agreement with the school district for confidentiality purposes for research conducted within the school system. 

36

 

in 2012 with most initially resettling in Charlotte, Durham, Greensboro, High Point, New

Bern, and Raleigh.46 The largest refugee populations in North Carolina include the

following countries of origin: Myanmar, Bhutan, Iraq, Cuba, Eritrea, Democratic

Republic of the Congo, and the Sudan.46

To meet diverse population needs, the school employs part-time and fulltime

onsite bilingual community liaisons who help school staff communicate with students

and families as well as assist with navigating the wide range of cultures within which the

school must work. The school also has an onsite fulltime social worker in addition to a

guidance counselor. The school provides initial placement testing, instruction that meets

grade level standards, and the opportunity for specialized introduction to educational

procedures and culture in the U.S. The school also coordinates efforts with the local

health (e.g., County Health Department, local pediatric community clinics) and social

service organizations for support of students and families (e.g., immunization

requirements, clothing, medical, and dental needs).

Family Day Description

Family day is a bi-annual tradition at the school that is held on a Saturday during

the fall and spring. Families are provided educational sessions from a variety of local

organizations, many of which specialize in work with refugees and immigrants (e.g.,

Immigration specialists from Elon Law School, FaithAction International House, and

Church World Service). Transportation is provided for attending families via school

buses (although some families did drive themselves). Childcare was provided for students

and children (siblings) in the school gym and families were divided among classrooms by

37

 

language needs for presentations from a variety of community organizations (e.g., a local

immigration law clinic, variety of community organization providing social services to

immigrants). Each organization was allocated 30 minutes to visit classrooms. Families

were separated by language (interpretation needs) and presenters rotated between the

classrooms based on a provided schedule by the school. Each interpreter (most were

Community Liaison school staff) provided interpretation to support the presentations and

help with questions from the families. The classroom groups included two Spanish

groups (due to the large number of Spanish speaking families), a combined Vietnamese

and Arabic speakers group, and a combined English and French speakers group. A

Burmese group was planned for; however, due to a transportation issue the Burmese

families did not make it to the family day.

Confidentiality, Translation, and Interpretation Services

Community liaisons employed by the school were trained by the principal

investigator regarding confidentiality and the scope of the research project within IRB

requirements of The University of North Carolina for community partners assisting with

interpretation and translation during research. Each Community Liaison provided written

documentation acknowledging their commitment to the confidentiality of the families and

data and their independent choice to participate in this research study. The community

liaisons also translated and interpreted all written materials used for this study (with the

exception of French, which was translated by an international student from The

University of North Carolina at Greensboro, and French interpretation was provided by a

former intern for the school).

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Nutrition Education Sessions

Nutrition education was provided by the primary investigator for the first 15–20

minutes of the allocated 30 minutes and included general nutrition topics (e.g., 5 a day,

sugar content beverages, basics on food labels, daily physical activity to reduce chronic

disease risk). Food models were also utilized during the nutrition education session (e.g.,

reading labels for sodium, fiber, fat). An educational handout was developed and

translated for the sessions and was available in the major languages in which the sessions

were conducted (e.g., English, Spanish, French, Arabic, Vietnamese, Burmese; see

Appendix B).

Obtaining Consent

After the initial nutrition education session, the parents received a translated flyer

regarding the study (see Appendix C). A description of the study was then provided

orally (interpreted into the primary language of the families, Appendix D). Parents were

not asked directly to provide individual consent, however, they were informed any verbal

feedback or physical feedback (i.e., raising their hand) during the data collection period

would be written down for use in the research study. This method of consent was chosen

and approved with the intention to alleviate potential peer pressure or burden on parents

to participate within the group setting. Parents were also offered an opportunity to ask

questions after data were collected and were informed that at this point their questions

would not be written down as any part of the research study. After the parents received

the study flyer and the script was read and interpreted, questions were initiated. All group

discussion questions were interpreted.

39

 

Data Collection

For questions 5–10 parents were asked to show their interest by raising their

hands. Research assistants (n=3) tallied the hands raised per topic and took notes during

this open-ended data collection. For questions 3–4 notes were taken by the primary

investigator and research assistant from these more open-ended questions regarding

dietary changes and concerns upon arrival to the U.S. Questions 1 and 2 were discarded

due to time constraints. No audio recording was utilized during data collection to reduce

any stress or barriers to participation for the parents.

Data Analysis

After the data collection, research assistants (n=3) met with the primary

investigator to reach consensus on data collected and on topics initiated by parents. A

summary was prepared based on the feedback and consensus between research assistants

and the primary investigator. Data were organized by the total number of “parents present

in the sessions” rather than “sample size” due to the consent process and inability to

define the exact sample number per group session. Themes were identified using

deductive content analysis as outlined by Elo and Kyngäs.45

Results

Caregivers were organized by language as the data were collected during sessions

organized by language. Language groups included French, Spanish, Vietnamese, English,

and Arabic speaking parents and caregivers (see Table 3.1) and for a total of N=38

caregivers.

40

 

Table 3.1

Demographic Information of Newcomer Caregivers (N=38)

Language Group n

Spanish 14

French/English 11

Vietnamese* 3

Arabic* 10 Note. Vietnamese speaking and Arabic speaking parents were grouped together during sessions

The most popular nutrition education topics identified (listed from highest to

lowest interest) included (a) attending a nutrition education session in their community in

the future, (b) assistance and education using food labels and tasting new recipes with

American/local ingredients, and (c) information regarding diets to reduce risk of chronic

disease (see Table 3.2). The least popular nutrition education and activities and topics

included participating in an assisted “shopping” tour as well as information regarding

children’s growth and nutrition.

Although parents did not report a high interest regarding children’s nutrition

related to growth and development, they did report a variety of concerns regarding the

diets of their children upon arrival to the U.S. (Table 3.3). Sugar and soda consumption

were regularly reported along with concerns of children’s preferences and intake of “fast

food” items like hamburgers and pizza. A variety of concerns were described regarding

fruits and vegetables ranging from the cost barriers, frustration with their children’s lack

of consumption as well as the lack of fruits and vegetables in school meals. Children’s

dislike for whole grain products was also described. Frustration with a lack of healthy

41

 

options provided in restaurants was consistently indicated. Nutrition related chronic

disease concerns (e.g., blood pressure, blood lipid levels) were also mentioned

independently by the Arabic/Vietnamese speaking group as well as the French/English

group but not in either Spanish speaking session (which were also the largest groups).

Table 3.2

Newcomer Caregiver’s Interest in Nutrition Education Topics by Language

Group/Session

Number Responding “Yes”

Nutrition Education Topic

Arabic/ Vietnamese

(n=13)

Spanish (n=14)

French/ English (n=11)

Total

Interested in attending Nutrition Education in Community in the future?

10 12 9 31

Interest in information/assistance in using food labels to make healthy food choices

10 13 7 30

Tasting new foods/recipes with healthy American foods

10 13 7 30

Diets to reduce risk of chronic disease (i.e., high blood pressure, diabetes, weight gain, heart disease)

9 13 7 29

Foods important for child’s growth and development

6 13 7 26

Shopping companion to help navigate American products and/or American grocery stores

8 6 8 20

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Table 3.3

Nutrition and Health Concerns of Newcomer Parents

Arabic/Vietnamese (n=13)

Spanish (n=14)

French/English (n=11)

Reduced sugar options for soda

Parent’s cholesterol (blood levels)

Concerned about child’s eating habits: junk/fast food, desire more natural foods

Concerned about pizza and hamburgers served at school

Concerns regarding affordability of produce (fruits/vegetables)

Concern about sodas Lack of healthy options

in restaurants Concerns getting

kids/child to eat fruits and vegetables

Kids do not like whole grain products

Information requested for foods good for vision, Vitamin A

Parent’s sodium levels and blood pressure

School lunch (concerned child needs more fruit/vegetables)

Parent’s dairy/milk intolerance concerns

Desired for their children to see sugar content of sodas

Discussion

The objectives of this study were to (a) examine the dietary perceptions,

behaviors and/or concerns of newcomer caregivers with upon arrival to the U.S., and (b)

examine the interests of newcomer caregivers regarding a variety of nutrition topics

and/or educational opportunities. Results indicate common concerns and interests despite

the wide range of cultures, languages, backgrounds, and experiences represented. To the

knowledge of the authors this study is unique in the diversity of the participants as well as

in the short length of time of residence with which the study was conducted (the school

43

 

serves newcomer students and families within their first year in the U.S.). This study adds

to the literature that has reported elevated nutrition and health risks with newcomer

groups by examining individual interests in topics and activities that have demonstrated

to play a role in risk (e.g., navigating stores and food insecurity, diet-related chronic

disease).

The highest ranked topic of interest for the families included attending future

nutrition education sessions within their communities. This interest in participating in

additional nutrition education is promising for future interventions with new arrivals.

Community-based nutrition education and health promotion is strongly suggested by

Rondinelli et al. in a study exploring the perceptions of former refugees and service

providers, and early intervention to promote incorporation of healthier foods in the diet

(or maintenance of healthy traditional foods) has been suggested by Pereira et al. due to

the rapid change and stabilization of food habits by newcomers in the first 12 months

after arrival.6,25 In addition, Peterman et al. suggest that organizations that serve

newcomers should “strategically devote resources to ensure successful early transition to

the U.S. food environment and long-term food security.”21 The strong suggestion of early

intervention and interest of caregivers for future nutrition education should be examined

for the potential to reduce negative dietary changes and chronic disease burden in groups.

Results of this study suggest strong interest in nutrition education and health

promotion and in addition to this interest to participate in more nutrition education,

caregivers provided feedback to the specific topics and/or activities in which they would

like to participate. Caregivers were very interested in taste testing new recipes with local

44

 

ingredients. Hadley et al. found African refugees reported high levels of difficulty

cooking American foods (63%, n=281 refugees) and Patil et al. found a high interest in

learning how to cook American foods with Liberian refugees (especially foods preferred

by their children).7,10 In a study with Latino parents by Flores et al., parents enjoyed taste

testing recipes (especially cultural recipes that were modified to improve the nutritional

quality).38 Due to the previously reported rapid dietary acculturation of newcomer

children and youth, it may be beneficial to provide parents with opportunities to learn

healthier versions of “American favorites.” Recipes that focus on quick and convenient

meals may also support long-term diet quality and combat the incorporation of less

healthy foods and fast foods which have been reported to increase as gender roles (e.g.,

women working more) and lifestyles shift in America (e.g., less time available to prepare

family meals).5,7,23,24,26,30,46

In addition to interest obtaining recipes and taste testing, parents also reported a

strong interest in learning more about how to use food labels. Nutrition education needs

regarding food label use has also been identified in other studies. For example, in a study

by Sharif et al., only 13% of Hispanic participants survey demonstrated adequate

comprehension of the food label and only 60% used it.46 In a study of the general

population in Canada, approximately one-third did not adequately understand the food

label.47 Food label use is important as it has been associated with improved food choices

and higher diet quality (e.g., less total calories, fat, improved fiber); however, there has

also been evidence that a sufficient amount of nutrition knowledge is necessary in

combination to food label use.48-50 For example, in another study with Hispanics,

45

 

nutrition label usage rarely or never influenced purchases when nutrition knowledge was

limited.51 A base of general nutrition knowledge appears to be required in order to best

utilize the food label to support healthy, more nutrient dense food choices. Future

nutrition education should include basic nutrition education and improvement of nutrition

knowledge in addition to knowledge and skills utilizing the food label. Improving

knowledge and use of food labels (e.g., reducing sodium, saturated fat, sugar) may be

especially promising in light of reported concerns for a variety of health related chronic

conditions in this study (and the literature).23-26

In addition to reported interest in nutrition education relating to chronic disease,

caregivers also brought up specific nutrition-related chronic disease concerns during the

open-ended discussion questions including sodium intake and blood pressure as well as

cholesterol levels and diet. Research examining health literacy regarding prevalent

chronic diseases (e.g., diabetes, hypertension) is limited as are interventions to reduce

chronic disease burden with these groups despite reported risks. Understanding health

literacy as well as cultural, language, and literacy needs and barriers with these groups is

key to addressing these disparities and developing targeted, tailored health promotion

strategies and messages. Some very basic resources (e.g., translated handouts by the U.S.

Committee for Refugee and Immigrants) exist for health care and service providers;

however, these resources are not targeted or tailored to individual groups.52 Tailored and

targeted resources have been found to be more successful in improving nutrition

knowledge and in supporting healthy behaviors (e.g., food choices, diet quality).53-56

46

 

In contrast from nutrition concerns by the adults themselves, there was less

interest in nutrition related to children’s growth and development; however, there was

concern about the dietary choices that their children were making, particularly with

regards to fast food types of items (e.g., pizza, hamburgers) and the lack of fruits and

vegetables they perceived available instead for their children at school. There was also

little reported interest in receiving assistance navigating grocery stores and food products.

Difficulty navigating stores and products in the U.S. has been found to be significantly

linked to food insecurity.10,12,21 Some difficulties navigating the U.S. food system may be

in part due to lack of prior experience for some groups. For example, in a study by

Dharod with South-Asian refugees, 97% of the women surveyed reported they did not

ever shop in a store for food prior to arrival (having grown and traded for most of their

food staples).25 In addition, in a preliminary study volunteers and service providers to

local refugee groups indicated that assistance navigating grocery stores is an area of

strong need.57 Hands-on assistance shopping, however, was the least appealing education

or training opportunity for caregivers in this study.

This study examined the interest in a variety of nutrition topics and activities that

have been associated with nutritional risk for newcomer families (e.g., difficulty

navigating products, stores, and chronic disease risk). While many studies have focused

on identifying risk factors in newcomer groups, few studies have investigated the interest

regarding related education topics and learning activities to address these risks. Despite

these new and unique findings, there are several limitations to this study. The lack of

sociodemographic information due to time constraints and invasiveness reduces the

47

 

context with which the data can be analyzed and interpreted. Although all families whose

children attend the school were invited to attend, it is possible more acculturated or

higher educated parents may have self-selected to attend to gain information and this

could influence the results. The nutrition education sessions prior to the data collection

may have encouraged interest in particular topics or nutrition and health overall. The

interest in topics and activities did not differentiate between levels of interest (e.g., very

interested, to somewhat interested) rather parents indicated interest vs. no interest (e.g.,

yes vs. no). Lastly, data were collected by note taking, which is not as preferable as audio

recording and transcribing sessions; however, the decision to not audio-record was

chosen to improve the comfort level of the families in participating in the study. Despite

this, several limitations measures were employed to reduce bias and inaccuracies in the

data collection and analysis (e.g., multiple members of the research group reached

consensus on topics initiated by parents during the open-ended discussion).

In summary, this study demonstrated high interest in receiving education in many

areas of nutrition and related health topics. This work suggests newcomers desire

nutrition education regarding recipes and taste testing and food label support, as well as

information regarding diet-related chronic diseases. Future interventions may focus on

promoting diet quality with taste testing and healthy recipe ideas, particularly to provide

resources to parents who are frustrated with fast food preferences of their children and

who wish to incorporate more fruits and vegetables. In addition, the adoption of

convenience and fast foods due to limitations in food preparation time in the rapidly

adopted American lifestyle warrants support of families to provide recipes that are quick

48

 

and simple as well as how to choose healthier convenience and fast food options.

Culturally relevant and appropriate education and interventions focusing on chronic

disease prevention and reduction are also an area for potential future research.

Examination of the efficacy of early interventions with newcomers in addressing their

interests and risk factors and the long term impact on diet quality, nutrition security,

and/or chronic disease risk should also be evaluated. Lastly, although groups share many

common interests and concerns, future nutrition education or health promoting

interventions or resources should be tailored and targeted to individual cultural groups to

support improved outcomes.

49

 

References

1. Monger, R., & Yankay, J. (2014, May). Annual Flow Report 2013: US Lawful

Permanent Residents. Retrieved from http://www.dhs.gov/publication/us-lawful-permanent-residents-2013

2. Martin, D. C., & Yankay, J. E. (2013). Annual Flow Report 2013: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_ 2013.pdf

3. US Citizenship and Immigration Services-RAIO-Asylum Division. (2009, March 6). Asylum Officer Basic Training Course. Eligibility Part I. Definitions; Past Persecution. Retrieved from http://www.uscis.gov/sites/default/files/USCIS/ Humanitarian/Refugees%20%26%20Asylum/Asylum/AOBTC%20Lesson%20Plans/Definition-Refugee-Persecution-Eligibiity-31aug10.pdf

4. Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Population Estimates and Projections. Retrieved from http://www.census.gov/content/dam/Census/library/publications/2015/demo/ p25-1143.pdf

5. Willis, M. S., & Buck, J. S. (2007). From Sudan to Nebraska: Dinka and Nuer refugee diet dilemmas. Journal of Nutrition Education and Behavior, 39(5), 273–280. doi:10.1016/j.jneb.2006.10.005

6. Pereira, C., Larder, N., & Somerset, S. (2010). Food acquisition habits in a group of African refugees recently settled in Australia. Health & Place, 16(5), 934–941. doi:10.1016/j.healthplace.2010.05.007

7. Patil, C., Hadley, C., & Nahayo, P. (2009). Unpacking dietary acculturation among new Americans: Results from formative research with African refugees. Journal of Immigrant and Minority Health, 11(5), 342–358. doi:10.1007/s10903-008-9120-z

8. Adekeye, O., Kimbrough, J., Obafemi, B., & Stack, R. (2014). Health literacy from the perspective of African immigrant youth and elderly: A PhotoVoice project. Journal of the Poor and Underserved, 25(4), 1730–1747. doi:10.1353/hpu.2014.0183

50

 

9. Coleman-Jensen, A., Rabbitt, M., Gregory, C., & Singh, A. (2015, September). Economic Research Report No. (ERR-194). Retrieved from http://www.ers.usda.gov/media/1896836/err194_summary.pdf

10. Hadley, C., Patil, C. L., & Nahayo, D. (2010). Difficulty in the food environment and the experience of food insecurity among refugees resettled in the United States. Ecology of Food and Nutrition, 49(5), 390–407. doi:10.1080/03670244.2010.507440

11. Hadley, C., Zodhiates, A., & Sellen, D. W. (2007). Acculturation, economics and food insecurity among refugees resettled in the USA: A case study of West African refugees. Public Health and Nutrition, 10(4), 405–412.

12. Hadley, C., & Sellen, D. (2006). Food insecurity and child hunger among recently resettled Liberian refugees and asylum seekers: A pilot study. Journal of Immigrant and Minority Health, 8(4), 369–375.

13. Dharod, J., Croom, J. E., & Sady, C. G. (2013). Food insecurity: Its relationship to dietary intake and body weight among Somali refugees women in the United States. Journal of Nutrition Education and Behavior, 45(1), 47–53. doi:10.1016/j.jneb.2012.03.006

14. Sharkey, J. R., Dean, W. R., & Nalty, C. C. (2013). Child hunger and the protective effects of Supplemental Nutrition Assistance Program (SNAP) and alternative food sources among Mexican-origin families in Texas border colonias. BMC Pediatrics, 13, 143. doi:10.1186/1471-2431-13-143

15. Quandt, S. A., Shoaf, J. I., Tapia, J., Hernández-Pelletier, M., Clark, H. M., & Arcury, T. A. (2006). Experiences of Latino immigrant families in North Carolina help explain elevated levels of food insecurity and hunger. Journal of Nutrition, 136(10), 2638–2644.

16. Munger, A. L., Lloyd, T. D., Speirs, K. E., Riera, K. C., & Grutzmacher S. K. (2015). More than just not enough: Experiences of food insecurity for Latino immigrants. Journal of Immigrant and Minority Health, 17(5), 1548–1556. doi:10.1007/s10903-014-0124-6

17. Iglesias-Rios, L., Bromberg, J. E., Moser, R. P., & Augustson, E. M. (2015). Food insecurity, cigarette smoking, and acculturation among Latinos: Data from NHANES 1999–2008. Journal of Immigrant and Minority Health, 17(2), 349–357. doi:10.1007/s10903-013-9957-7

18. Anderson, L., Hadzibegovic, D. S., Moseley, J. M., & Sellen, D. W. (2014). Household food insecurity shows associations with food intake, social support utilization and dietary change among refugee adult caregivers resettled in the United

51

 

States. Ecology of Food and Nutrition, 53(3), 312–332. doi:10.1080/03670244.2013.831762

19. Buscemi, J., Beech, B. M., & Relyea, G. (2011). Predictors of obesity in Latino children: Acculturation as a moderator of the relationship between food insecurity and body mass index percentile. Journal of Immigrant and Minority Health, 13(1), 149–154. doi:10.1007/s10903-009-9263-6

20. Leung, C. W., Williams, D. R., & Villamor, E. (2012). Very low food security predicts obesity predominantly in California Hispanic men and women. Public Health Nutrition, 15(12), 2228–2236. doi:10.1017/S1368980012000857

21. Peterman, J. N., Wilde, P. E., Silka, L., Bermudez, O. I., & Rogers, B. L. (2013). Food insecurity among Cambodian refugee women two decades post resettlement. Journal of Immigrant and Minority Health, 15(2), 372–380. doi:10.1007/s10903-012-9704-5

22. Bawadi, H. A., Ammari, F., Abu-Jamous, D., Khader, Y. S., Bataineh, S., & Tayyem, R. F. (2012). Food insecurity is related to glycemic control deterioration in patients with type 2 diabetes. Clinical Nutrition, 31(2), 250–254. doi:10.1016/j.clnu.2011.09.014

23. Vue, W., Wolff, C., & Goto, K. (2011). Hmong food helps us remember who we are: Perspectives of food culture and health among Hmong women with young children. Journal of Nutrition Education and Behavior, 43(3), 199–204. doi:10.1016/j.jneb.2009.10.011

24. Wilson, A., & Renhazo, A. (2014). Intergenerational differences in acculturation experiences, food beliefs, and perceived health risks among refugees from the Horn of Africa in Melbourne, Australia. Public Health Nutrition, 18(1), 176–188. doi:10.1017/S1368980013003467

25. Rondinelli, A. J., Morris M. D., Rodwell T. C., Moser K.S., Paida P., Popper S.T., & Brouwer K. C. (2011). Under- and over-nutrition among refugees in San Diego County, California. Journal of Immigrant and Minority Health, 13(1), 161–168. doi:10.1007/s10903-010-9353-5

26. Franzen, L., & Smith, C. (2009). Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite, 52(1), 173–183. doi:10.1016/j.appet.2008.09.012

27. Batis, C., Hernandez-Barrera, L., Barquera, S., Rivera, J. A., & Popkin, B. M. (2011). Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. Journal of Nutrition, 141(10), 1898–1906. doi:10.3945/jn.111.141473

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28. Santiago-Torres, M., Adams, A. K., Carrel, A. L., LaRowe, T. L., & Schoeller, D. A. Home food availability, parental dietary intake, and familial eating habits influence the diet quality of urban Hispanic children. Child Obesity, 10(5), 408–415. doi:10.1089/chi.2014.0051

29. Beck, A.L., Tschann, J., Butte, N.F., Penilla, C., & Greenspan, L. C. (2014). Association of beverage consumption with obesity in Mexican American children. Public Health Nutrition, 17(2), 338–344. doi:10.1017/S1368980012005514

30. Garnweidner, L. M., Terragni, L., Pettersen, K. S., & Mosdol, A. (2012). Perceptions of the host country’s food culture among female immigrants from Africa and Asia: Aspects relevant for cultural sensitivity in nutrition communication. Journal of Nutrition Education and Behavior, 44(4), 335–342. doi:10.1016/j.jneb.2011.08.005

31. Peterman, J. N., Silka, L., Bermudez, O. I., Wilde, P. E., & Rogers, B. L. (2011). Acculturation, education, nutrition education, and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. Journal of the American Dietetic Association, 111(9), 1369–1374. doi:10.1016/j.jada.2011.06.005

32. Tiedje, K., Wieland, M. L., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2014). A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States. International Journal of Behavioral Nutrition and Physical Activity, 11, 63. doi:10.1186/1479-5868-11-63

33. Anderson, L. C., Mah, C. L., & Sellen, D. W. (2015). Eating well with Canada’s food guide? Authoritative knowledge about food and health among newcomer mothers. Appetite, 91, 357–365. doi:10.1016/j.appet.2015.04.063

34. Mannion, C. A., Raffin-Bouchal, S., & Henshaw, C. J. (2014). Navigating a strange and complex environment: Experiences of Sudanese refugee women using a new nutrition resource. International Journal of Women’s Health, 16(6), 411–422. doi:10.2147/IJWH.S56256

35. Barnes, D. M., & Almasy, N. (2005). Refugees’ perceptions of healthy behaviors. Journal of Immigrant Health, 7(3), 185–193.

36. Choi, S. E., Rush, E., & Henry, S. (2013). Health literacy in Korean immigrants at risk for type 2 diabetes. Journal of Immigrant Health, 15(3), 553–559. doi:10.1007/s10903-012-9672-9

37. Drummond, P., Mizan, A., Burgoyne, A., Wright, B. (2011). Knowledge of cardiovascular risk factors in west African refugee women living in western

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Australia. Journal of Immigrant Minority Health, 13(1), 140–148. doi:10.1007/s10903-010-9322-z

38. Flores, G., Maldonado, J., & Durán, P. (2012). Making tortillas without lard: Latino parents’ perspectives on healthy eating, physical activity, and weight-management strategies for overweight Latino children. Journal of the Academy of Nutrition and Dietetics, 112(1), 81–89. doi:10.1016/j.jada.2011.08.041

39. Fisher-Hoch, S. P., Vatcheva, K. P., Rahbar, M. H., & McCormick, J. B. (2015). Undiagnosed diabetes and pre-diabetes in health disparities. PLoS ONE, 10(7), e0133135. doi:10.1371/journal.pone.0133135

40. Mulasi-Pokhriyal, U., Smith, C., & Franzen-Castle, L. (2012). Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9–18 years. Public Health Nutrition, 15(1), 176–185. doi:10.1017/S1368980011001649

41. Hrboticky, N., & Krondl, M. (1984). Acculturation to Canadian foods by Chinese immigrant boys: Changes in the perceived flavor, health value and prestige of foods. Appetite, 5(2), 117–126. doi:10.1016/S0195-6663(84)80031-8

42. Smith, C., & Franzen-Castle, L. (2012). Dietary acculturation and body composition predict American Hmong children’s blood pressure. American Journal of Human Biology, 24(5), 666–674. doi:10.1002/ajhb.22295

43. Benbenek, M. M., & Garwick, A. W. (2012). Enablers and barriers to dietary practices contributing to bone health among early adolescent Somali girls living in Minnesota. Journal for Specialists in Pediatric Nursing, 17(3), 205–214. doi:10.1111/j.1744-6155.2012.00334.x

44. Martin, D. C., & Yankay, J. E. (2012). Annual Flow Report 2012: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ ois_rfa_fr_2012.pdf

45. Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62, 107–115. doi:10.1111/j.1365-2648.2007.04569.x

46. Sharif, M. Z., Rizzo, S., Prelip, M. L., Glik, D. C., Belin, T. R., Langellier, B. A., . . . Ortega, A. N. (2014). The association between nutrition facts label utilization and comprehension among Latinos in two east Los Angeles neighborhoods. Journal of the Academy of Nutrition and Dietetics, 114(12), 1915–1922. doi:10.1016/j.jand.2014.05.004

54

 

47. Sinclair, S., Hammond, D., & Goodman, S. (2013). Sociodemographic differences in the comprehension of nutritional labels on food products. Journal of Nutrition Education and Behavior, 45(6), 767–772. doi:10.1016/j.jneb.2013.04.262

48. Miller L. M., & Cassady, D. L. (2015). The effects of nutrition knowledge on food label use. A review of the literature. Appetite, 92, 207–216.  

49. Ollberding, N. J., Wolf, R. L., & Contento, I. (2010). Food label use and its relation to dietary intake among US adults. Journal of the Academy of Nutrition and Dietetics, 110(8), 1233–1237. doi:10.1016/j.jada.2010.05.007

50. Post, R. E., Mainous, A. G. III, Diaz, V. A., Matheson, E. M., & Everett, C. J. (2010). Use of the nutrition facts label in chronic disease management: Results from the National Health and Nutrition Examination Survey. Journal of the American Dietetic Association, 110(4), 628–632. doi:10.1016/j.jada.2009.12.015

51. Carrillo E., Varela, P., & Fiszman, S. (2012). Influence of nutritional knowledge on the use and interpretation of Spanish nutritional food labels. Journal of Food Science, 77(1), H1–H8. doi:10.1111/j.1750-3841.2011.02479.x

52. The US Committee for Immigrants and Refugees. (2016). Resources and reports. Arlington, VA: Author. Retrieved from http://refugees.org/research-reports/

53. Skinner, C. S., Campbell, M. K., Rimer, B. K., Curry, S., & Prochaska, J. O. (1999). How effective is tailored print communication? Annals of Behavioral Medicine, 21(4), 290–298.

54. Eyles, H. C., & Mhurchu, C. N. (2009). Does tailoring make a difference? A systematic review of the long-term effectiveness of tailored nutrition education for adults. Nutrition Reviews®, 67(8), 464–480. doi:10.1111/j.1753-4887.2009.00219.x

55. Kreuter, M. W., Lukwago, S. N., Bucholtz, D. C., Clark, E. M., & Sanders-Thompson, V. (2002). Achieving cultural appropriateness in health promotion programs: Targeted and tailored approaches. Health Education & Behavior, 30(2), 133–146.

56. Kris-Etherton, P. M., Akabas, S. R., Bales, C. W., Bistrian, B., Braun, L., Edwards, M. S., . . . Van Horn, L. (2014). The need to advance nutrition education in the training of health care professionals and recommended research to evaluate implementation and effectiveness. The American Journal of Clinical Nutrition, 99(5), 1153S–1166S. doi:10.3945/ajcn.113.073502

57. Sastre, L., & Haldeman L. (2015). Environmental, nutrition and health issues in a US refugee resettlement community. MEDICC Review, 17(4), 18–24.

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CHAPTER IV

MOVING LESS, NEW FOODS, AND GAINING WEIGHT: PERCEPTIONS,

KNOWLEDGE, CONCERNS, AND INTERESTS FROM FOCUS GROUPS WITH NEWCOMER YOUTH

Abstract

Introduction: In 2012, North Carolina ranked in the top ten for refugee resettlement.

Newly-arrived youth are understudied, but experience rapid dietary acculturation. These

changes, in combination with household food insecurity, put them at risk for adverse

long-term health outcomes. The objective of this study was to examine the nutrition

perceptions, interests, and needs for newly-arrived youth.

Methods: A facilitated group discussion (n=7) and semi-structured interviews (n=2)

were conducted (with French and Spanish interpretation) with high school students

between May and June 2015. Countries of origin (n=9) included Pakistan, Senegal,

Niger, Liberia, Somalia, Mexico, Honduras, and Rwanda. Notes were handwritten by the

principal investigator and a research assistant during focus groups, compared for

accuracy, and analyzed using content analysis to identify themes.

Results: Students reported pre-arrival diets focused on starches, meats, and salads and

the addition of new “American” favorites including pizza, hamburgers, and fried chicken.

Students reported their diets to be similar to pre-arrival, with a reduction in physical

activity as the greatest change. Physical activity preferences varied between genders.

Female students initiated concerns with weight gain and interest in weight loss diets.

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Students’ perceptions of health focused on maintaining “balance,” the need to be active,

limiting junk food and soda, and eating fruits and vegetables.

Conclusions: Results from this study demonstrate a basic understanding of nutrition,

negative dietary acculturation, and reductions in physical activity upon arrival. Barriers

and promoters for physical activity should be further explored, particularly with evidence

of negative diet changes and weight gain concerns.

Introduction

In 2013, 990,553 individuals became lawful residents of the U.S.1 Of these

individuals 10.4% (103,191) were between 5 and 14 years of age and 16.7% (165,893)

were between the ages of 14 and 24.1 In addition to general immigration, 69,909 entered

the U.S. as refugees and 33.8% were under the age of 18 (23,647). Individuals entering

under refugee status under the Immigration and Nationality Act 101(a)(42) are “unable or

unwilling to return to his or her country of nationality because of persecution or a well-

founded fear of persecution on account of race, religion, nationality, membership in a

particular social group, or political opinion.”3

The consistent, annual immigration rates (990,553 in 2013, 1,031,632 in 2012,

and 1,062,040 in 2011) are rapidly changing the ethnic makeup of the U.S.1,4 The

foreign-born population is estimated by the U.S. Census Bureau to grow by 85% with

foreign-born individuals under the age of 18 expected to increase 29.8% between 2014

and 2060.4 As the makeup of the U.S. rapidly shifts over the next few decades, the health

and nutrition needs of these groups must be examined to support national, state, and local

health priorities and polices (e.g., Healthy People, Dietary Guidelines) that will address

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the health and nutrition needs of an increasingly ethnically and culturally diverse

population. Incoming groups, particularly refugee groups, have not been well studied

despite demonstrated risks. Immigrant and refugee adolescents are especially

understudied despite their numbers and risks.

Newcomer youth are exposed to new foods as they attend school and dietary

change is far more rapid and frequently results in family frustrations as youth rapidly

adopt a variety of unhealthful foods (e.g., Sugar-sweetened beverages (SSBs),

convenience and fast foods (FFs)).5-15 School offers opportunities to try a new variety of

foods—often fast food-like meals (e.g., pizza, hamburgers) but also milk, other sources

of dairy, and local fruits and vegetables. Adoption of new foods therefore demonstrates

both positive (e.g., increases in calcium) and negative dietary effects (e.g., increases in fat

consumption, total calories) as well as increases in BMI and blood pressure with dietary

changes.16-20 Less acculturated adolescents also report higher consumption of fruits and

vegetables and better overall diet quality which suggests that maintaining cultural identity

and foods may be protective of diet quality.21-23

Not all newcomer groups acculturate at equal rates or with equal outcomes.23–25 In

a study by Allen et al., Latino and Asian youth were compared over several generations.

Asian youth maintained healthy behaviors or improved regarding diet quality and

physical activity, whereas Latino youth showed decreased diet quality over time (e.g.,

decreases in fruit and vegetables, increases in sodas).23 In a study by Arcan et al., Somali,

Hispanic, Hmong, and white adolescents were compared and shared trends of low fruit,

vegetable, and dairy consumption but high fast food consumption, with Hispanic and

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Somali teens consuming the most fast food.25 Time, taste, and convenience have been

described as influencing factors in increasing consumption of fast food and convenience

foods in a study with Mexican, Cambodian, Sudanese, and Somalian adolescents.13 In

another study with Mexicans, within one generation in the U.S., influence of the

traditional diet was lost, suggesting rapid change.26 These studies support findings with

caregivers cited previously in which parents report their children request and desire

Western foods (especially fast foods), but also indicate acculturation is complex and may

vary distinctly between ethnic groups and result in positive and negative dietary changes.

Adolescents of immigrant and refugee households also often play a more active

role (in comparison to whites) in shopping and preparing foods for the family, and have

more independence choosing or preparing their own foods.10,19,27,28 Additionally, the role

of adolescent newcomers as cultural brokers may increase their influence on the family

diet.29 Different cultures report differences in the power adolescents hold, with mixed

influence reported in African homes and less influence in some Asian cultures.8,25,29

Newcomer adolescents have also reported heightened sensitivity to peer pressure, social

expectations, and body image. Studies with African, Southeast Asian, and Hispanics all

reported attempts to modify their diet or increase physical activity in order to control their

weight or “look/feel good.”10,21,25,27,29,30 Generational differences in perception of weight

with parents often favoring attempts to increase children’s weight, while adolescents

report resistance.25,29

In summary, adolescents are exposed to a variety of new foods upon arrival to the

U.S., especially as they enter the school system. Changes vary between groups and may

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result in rapid healthful and/or risky dietary choices. Newcomer adolescents also

demonstrate body image concerns as well as reports of dieting or increased activity to

modify body weight. Literature regarding attitudes, knowledge, perceptions, and interests

of newcomer adolescents is limited, despite the potential health and nutrition risks. The

objective of this study was to examine nutrition and health knowledge, changes (e.g.,

food choices, physical activity), perceptions, and interests of newcomer adolescents.

Methods

Study Design

Facilitated group session and semi-structured interviews were conducted during

school days between May and June 2015 at a school for newcomer youth in North

Carolina.ii Sessions occurred during Physical Education (P.E.) and Health classes for

middle and high school students. Questions were based on a semi-structured guide that

was content validated by experts (n=3) in the field of immigrant and refugee nutrition and

health and/or family focused nutrition (see Appendix E). Questions targeted nutrition and

health-related changes, concerns, and interests. The study was approved by the

institutional review board at The University of North Carolina at Greensboro and the

school district’s Research Review Committee prior to recruitment and data collection.

Written parental consent as well as written and/or oral informed student assent was

obtained prior to any data collection in their primary language. An interpreter was

available for assent for the students as well as to answer any questions regarding the

study.

                                                            ii This description of the school is the wording required in agreement with the school district for confidentiality purposes for research conducted within the school system.

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Site Description

The study was conducted at a school for newcomer youth in North Carolina that

provides a specialized environment for students during their first year in the U.S. North

Carolina ranked in the top ten in 2012 for refugee resettlement and receives high numbers

of immigrants annually.8 North Carolina was home to 749,426 immigrants in 2013 with

31.9% naturalized U.S. citizens with high numbers of Asian and Latin American

immigrant populations.31 There were approximately 350,000 unauthorized immigrants in

North Carolina in 2013.31 Also, there were 2,110 refugees who arrived in North Carolina

in 2012, most of whom initially resettled in Charlotte, Durham, Greensboro, High Point,

New Bern, and Raleigh.32 The largest refugee populations in North Carolina include the

following countries or origin: Myanmar, Bhutan, Iraq, Cuba, Eritrea, Democratic

Republic of the Congo, and the Sudan.32

To meet the needs of a very diverse student population the school employs part-

time and fulltime onsite bilingual community liaisons who help school staff communicate

with students and families. The school also has an onsite fulltime social worker in

addition to a guidance counselor. The school provides initial placement testing and

instruction that meets grade level standards, in addition to opportunity for specialized

instructions regarding educational procedures and culture in the U.S. The school also

coordinates efforts with the local health (e.g., County Health Department, local pediatric

community clinics) and social service organizations for support of students and families

(e.g., immunization requirements, clothing, medical, and dental needs).

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Recruitment and Inclusion Criteria

All students in P.E. and Health classes between the ages of 12 and 17 who spoke

English, Spanish, Arabic, French, Vietnamese, or Burmese were provided with a

recruitment packet that included a study flyer as well as two parent consent forms (see

Appendixes F, G, and H). These languages were chosen based on the current populations

at the school as well as the availability of staff for translation of study materials and

interpretation. Packets were distributed by the P.E. and Health teachers at the school. The

packets were collected on a regular basis over a four-week period. Students who returned

packets with parental consent were given the opportunity to participate in the focus

groups and/or a survey given at the school. The school system and school suggested

inclusion of students more proficient in English to ease the burden on the school’s

community liaisons (interpreters). The final focus groups were selected based on English

proficiency and/or Spanish/French, as additional Spanish and French translators (non-

school staff) were recruited and available for sessions, allowing for expansion of

inclusion criteria without burdening of school staff. Students in the final focus groups

were invited to participate based on English, French, and/or Spanish proficiency.

Confidentiality, Translation, and Interpretation Services

Community liaisons employed by the school and two non-school staff interpreters

(Spanish and French) were trained by the principal investigator regarding confidentiality

and the scope of the research project within IRB requirements of The University of North

Carolina for community partners assisting with interpretation and translation. Each

Community Liaison and interpreter provided written consent acknowledging their

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commitment and understanding of confidentiality of the students and data, as well as their

independent choice to participate in this research study prior to any translation and/or

interpretation. The community liaisons translated all written materials used for this study

(e.g., see Appendixes F, G, and H) with the exception of French, which was translated by

an international student from The University of North Carolina at Greensboro.

Interpretation during sessions was provided by a bilingual Spanish community member

and a French-speaking community member who were trained by the principal

investigator regarding confidentiality and the scope of the research project within IRB

requirements of The University of North Carolina at Greensboro for community partners

assisting with interpretation and translation.

Facilitation Group Sessions

The group session and semi-structured interviews were held during P.E. and

Health class time in an unused classroom. Each session lasted approximately 45 minutes.

A Spanish interpreter was available for the first session (group discussion) and a French

interpreter was available to assist with the second session (semi-structured interview).

Students were lead through the session based on the guide which began with general

icebreakers (e.g., “a) Let’s start of by introducing ourselves, by name, where you are

from, and something about you, what you like to do, or something that is important to

you, b) Now let’s go around and share one of your favorite foods”; see Appendix E).

Students were provided the option to be skipped or to not participate in responding to any

of the questions with which they were uncomfortable.

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Data Collection and Analysis

The principal investigator and a research assistant took handwritten notes

throughout the sessions. No audio recording was utilized during data collection to reduce

any stress or barriers to participation for the participants. After each session, the primary

investigator and research assistant met to compare notes and reach consensus on themes.

Themes were organized in categories by question topics. Data were analyzed for themes

using content analysis as described by Elo and Kyngäs and was listed in order of

decreasing frequency of how the consistency with which the topic was initiated or agreed

upon by students.33

Results

The facilitated group discussion (n=7) and semi-structured interview (n=2)

included students of both genders (n=6 females, n=3 males) and a total of eight

nationalities were represented (see Table 4.1). The facilitated group discussion included

the greatest variety of nationalities and included a Spanish interpreter. The semi-

structured interviews included a brother and sister pair from Senegal who spoke English

and French and a French interpreter was present. Both sessions utilized the same

discussion guide (see Appendix E).

The sessions opened with ice-breaker questions regarding hobbies and favorite

foods and then a general discussion of health and health related behaviors (see Table 4.2).

Health status was related to “feeling good, limiting junk food” and staying active. Health

was also dependent upon a concept of balance (e.g., “a little bit of everything, not too

much”). Physical activity was the most frequently reported behavior to support good

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health. After physical activity, vegetable, fruit, and milk consumption were identified to

support good health. Consumption of soda, oil, salt, and sugar were directly identified as

foods that made you less healthy. Food safety concerns were also brought up by students

(e.g., importance of washing your hands/food, concerns of food at school because they

were uncertain how long it had been sitting out).

Table 4.1

Adolescent Group Demographics by Session Type

Session Type

Demographic Facilitated Group Discussion Semi-structured

Interviews Sample Size n=7 n=2

Gender Male Female

n=2 n=5

n=1 n=1

Nationalities Represented

Pakistan, Niger, Liberia, Somalia, Mexico, Honduras, Rwanda

Senegal

Table 4.2

Adolescent Health Themes

Discussion Topic Themes

What does it mean to be healthy?

“a little bit of everything, not too much, exercise, eating variety, still eat junk not too much”

Not too much junk Active (being active) “feel good”

What makes you healthy? What can you do to be healthy?

Active (being active) Eating Vegetables Eating fruit Milk

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Table 4.2

Cont.

Discussion Topic Themes§

What makes you less healthy? Soda Not washing hands/not washing food Too much oil, salt, sugar,

§ Themes listed in order of decreasing frequency

Discussion of students’ diets and physical activity revealed many trends,

perceptions, and behaviors (see Table 4.3). Chicken and rice were consistently reported

as a favorite Pre-U.S. meal as well as salads. Sandwiches and hamburgers were also

described as favorite Pre-U.S. foods. New favorite foods in the U.S. included energy

dense, fast food-type foods with pizza as the first choice followed by hamburgers, fried

chicken, and high-calorie beverages (e.g., milkshakes, frappes, sodas).

When asked about any nutrition concerns, all concerns were weight related,

including concerns with weight gain, interest in diets to lose weight, as well as reported

changes in weight. Students perceived changes to their weight, but did not believe their

diets had changed upon arrival to the U.S. (see Table 4.3). Only female students brought

up weight concerns. In the first focus group session, the girls discussed weight concerns

and in the second focus group session the sibling of the female student initiated the topic

by describing his sister’s weight-related concerns.

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Table 4.3

Adolescent Diet Themes

Discussion Topic Themes§

Favorite foods before coming to the U.S.? Rice, chicken/meat, salad, sandwich/hamburger

Favorite foods now in the U.S.? Pizza, hamburger, fried chicken, high calorie beverages (milkshake, frappe, sodas)

Foods or celebrations with special meaning?

Feast breaking Ramadan Avoidance of pork Llama (Senegal) consumed on special

occasions

Any nutrition concerns or topics you would like more information about?

Concerns with gaining weight* Diets to lose weight* Concerns that eating same amount of

food as before but now gaining weight* § Themes listed in order of decreasing frequency * All concerns related to weight were reported by female students (i.e., gaining, needing to lose weight, diets to lose weight)

Students perceived their current diet as similar to their pre-arrival diet; however,

their level of physical activity was consistently described as having experienced the most

change (physical activity was reported to have decreased among all genders; see Table

4.4). Physical activity preferences varied by gender with males reporting preference for

futbol (soccer) and females reporting a preference for basketball. Students described the

variety of ways they were physically active in their home countries and how this had

changed upon arrival to the U.S. Prior to arriving to the U.S., students reported they had

more opportunities to walk in their daily lives (e.g., walking to school, visiting others), as

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well as in games or sports they did not have the same access to in the U.S. (e.g., cricket,

badminton, swimming).

Table 4.4

Adolescent Physical Activity Themes

Discussion Topic Themes§

What are some of the biggest changes/differences with your diet/activity level in the U.S.? Why do you think this is?

Less active, less walking (used to walk more)

Diet perceived as similar in U.S. to before arrival

Produce perceived to have less taste, milk similar in taste

Dislike for “mixed” dishes (casseroles)

Activity Preferences Soccer/futbol (males) Basketball (females)

Pre-Arrival to U.S. Activities (students reported they no longer had access to these activities)

Cricket Badminton Swimming “Games”*

§ Themes listed in order of decreasing frequency * Students described a variety of outside games, many using a ball (but they couldn’t remember the name or provide a name in English)

Discussion

The objective of this study was to examine nutrition and health knowledge,

changes (e.g., food choices, physical activity), perceptions, and interests of newcomer

youth. A unique characteristic of this study, as far as the authors are aware, is the short

timeline the participants had resided in the U.S. and the diversity (nationality/ethnicity) of

the study population (students who attend the Newcomer’s School have been the U.S. for

less than a year, with some only a few weeks/months). Few studies have investigated diet

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and physical activity so close to arrival. Within this short timeline, newcomer adolescents

already report many changes to their physical activity and diet. The consistency of

identified themes within a diverse group of students suggests some commonality in the

experiences as they arrive and transition to life in the U.S.

Sessions revealed students defined their health as “how you feel” and

incorporated a concept of “balance” supported by physical activity, limiting junk foods,

and eating fruits and vegetables. Students reported that sugar, oil/fat, salt, and soda would

negatively impact their health. Kim et al. found Hmong youth related physical activity

and consumption of fruits and vegetables as supportive of good health.29 Physical activity

was the behavior most frequently identified with supporting good health, and it was also

the behavior most perceived to have changed upon arrival to the U.S. Students reported

reductions in their physical activity and lack of access to the types of activities in which

they participated prior to arrival (e.g., cricket, swimming).

Several other studies with newcomer youth have found reported decreases in

physical activity in the U.S.;8,27,29,35 however, Allen et al. (in a comparison of first-

through third-generation Hispanic and Asian youth) found physical activity was

perceived to increase over time. Reductions in physical activity have most frequently

been associated with changes to daily lifestyle (e.g., no longer walking to school and

friends’ homes, less physically demanding chores) as well as less safe space and

time.8,29,35,36 Results from this study support previous findings that physical activity is

reduced upon arrival to the U.S. due to a variety of factors.

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While physical activity was identified most consistently as the greatest “change,”

students did report many new favorite foods in the U.S. which now include many fast

foods such as pizza, hamburgers, and fried chicken. Students reported many new foods

they enjoy and had incorporated into their diets while also reporting their diet had

experienced little change upon arrival. It is possible that students are maintaining

traditional foods at home and incorporating new foods at school; therefore, they do not

perceive a change to their diet (or at least to their traditional diet). In a study by Renzaho

et al., newcomer African youth in Australia reported they still consumed their traditional

diets while their parents reported they were rapidly acculturating to a westernized diet;

therefore, perception of dietary acculturation may likely vary between generations and

may not be accurately portrayed. This study provides evidence that dietary acculturation

may be difficult to measure with newcomer students and that more quantitative methods

may be preferable to identify specific changes to the frequency of consumption of food

groups as well as the transition to a westernized diet and the incorporation of non-

traditional foods.

Favorite new foods in the U.S. did not include any fruits or vegetables, but

focused on fast food-like items (e.g., pizza, fried chicken). Incorporation and increased

consumption of fast foods and convenience foods by newcomer youth has been reported

in other studies.8,10,35,37 For example, in a study by Arcan et al., fast food consumption

was found to be equal or higher between Somali, Hispanic, and Hmong than white

adolescents, with significant differences between groups; Somali and Hispanic students

consumed the most fast food (approximately double the intake in comparison to whites).

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In addition, in a study by Stang et al., Hmong adolescents were found to have comparable

fast food consumption behaviors to white students. Fast food consumption may also be

associated with poor health outcomes, as demonstrated by a study by Hsieh et al., in

which proximity to fast food restaurants was significantly associated with insulin

resistance in Hispanic youth.38 Acculturate Studies have reported decreases in dietary

quality and increases in weight and other related concerns as diets change.16,20,21 A study

by Smith and Franzen-Castle revealed that over time in the U.S., BMI was found to

increase and correlate with increases in blood pressure in Hmong youth.18

Although not all studies have measured weight or BMI status of newcomer

adolescents, many studies have examined weight-related concerns of newcomer

adolescents and found strong concerns about weight gain, body dissatisfaction, and a

variety of behaviors to reduce weight (e.g., including restrictions of portions, disordered

eating, increasing physical activity, etc.).8,25,27,30,36 These findings are supported by results

in this study which found concerns regarding weight gain. Interestingly, only female

students reported concerns regarding their weight and interest in losing weight and

dieting. In a study by Lopez et al., female Hispanic adolescents were more likely than

males to report disordered eating patterns.39 In addition, some studies have identified

generational differences in weight perception with parents preferring weight gain (as a

sign of social status and health), whereas other studies have found parents to have

concerns about their children’s weight gain and attempts to help their children lose

weight.8,10,30 These contradicting trends have been reported in both Hmong and African

families.

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Differences in body image and dieting behaviors have also been reported between

groups and genders with newcomers. In a study by Arcan et al., adolescents of both

genders were similar in body satisfaction; however, female adolescents reported being

more likely to diet to lose weight and participate in unhealthy weight control behaviors.

Hmong female and male adolescents in comparison to Hispanic, white, and Somali

adolescents were more likely to report dieting and unhealthy weight control behaviors,

and Somali girls had much higher rates of dieting and unhealthy weight control behaviors

in comparison to white and Hispanic students. In a study by Stang et al., Hmong male

and female adolescents were more likely than white adolescents to report dieting, weight

concerns, and extreme unhealthful weight control. Results from this study and others

suggest greater body dissatisfaction and weight control behaviors in newcomer

adolescents, particularly girls. Furthermore, other studies used direct survey questions

regarding weight concerns, body image, and dieting behaviors, and in contrast during this

study, topics were initiated by girls without prompting, which may further reinforce the

concerns of adolescents (particularly girls) regarding body image and weight. It is also

unknown if body dissatisfaction develops upon arrival and exposure to U.S. culture; thus,

perceptions should be further explored.

In the Project EAT study by Neumark-Sztainer et al., a diverse group of

adolescents consistently identified a variety of weight-related concerns, risky weight

management behaviors, and poor body image in both genders.40 In a longitudinal follow-

up Project EAT-II study, dieting behaviors with adolescents were significantly associated

with skipping breakfast (females) and binge eating (males and females), as well as

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decreases in physical activity (males) and increases in BMI over time (males and

females).41 The long-term effects of poor body image and dieting behaviors may be

associated with increased health risk (BMI, reductions in physical activity) and should be

further examined and may require incorporation of interdisciplinary experts (e.g.,

psychology, counseling).

Although there are many findings worth further exploration, there are also

limitations to this study. Students were identified by language proficiency in English;

therefore, students may have been included who were more acculturated. In addition, no

Arabic, Vietnamese, or Burmese translators were available for focus groups which

deterred participation by adolescents of several nationalities (other studies have reported

many body image and dieting issues with Southeast Asian youth, e.g., Hmong; however,

no Southeast Asian students were able to be included in these focus groups). Both

genders were also not equally represented; therefore, the stark contrast in reported weight

concerns may have been different if more male students had participated (especially as

other studies have found weight concerns with males). In addition, focus groups were

conducted with both genders present and results may have varied if it had been possible

to separate male and female students. It is also noteworthy that over time, more changes

(both positive and negative) to behaviors may occur and that results identified in this

study may worsen or improve.

Although limitations exist, this study is unique in that very newly-arrived students

participated and involved a more diverse student population than other studies. This study

identified trends in weight concerns, dietary acculturation, and a reduction of physical

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activity also reported in other studies with newcomer youth. Results from this study and

others demonstrate a strong risk for poor health outcomes due to the poor changes to the

diet and reduction of physical activity. Future work should further clarify specific

changes to diet and physical activity including assessment of pre-arrival trends and an

exploration of influencing factors on dietary and lifestyle changes. Furthermore, many

groups remain poorly understood and trends and differences between nationalities,

cultures, and ethnic groups should be further explored in order to develop targeted,

relevant nutrition and health-promoting resources and interventions.

In addition, research and interventions should explore improving access to

physical activity and support positive dietary changes that may help to maintain healthy

weight and alleviate body and weight dissatisfaction. Work with schools to improve

nutrition education, healthy body image support, cooking, and physical activity

opportunities would likely benefit all adolescents in the U.S. and may have the potential

to reduce long-term chronic disease burden.

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References

1. Monger, R., & Yankay, J. (2014, May). Annual Flow Report 2013: US Lawful

Permanent Residents. Retrieved from http://www.dhs.gov/publication/us-lawful-permanent-residents-2013

2. Martin, D. C., & Yankay, J. E. (2013). Annual Flow Report 2013: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_ 2013.pdf

3. US Citizenship and Immigration Services-RAIO-Asylum Division. (2009, March 6). Asylum Officer Basic Training Course. Eligibility Part I. Definitions; Past Persecution. Retrieved from http://www.uscis.gov/sites/default/files/USCIS/ Humanitarian/Refugees%20%26%20Asylum/Asylum/AOBTC%20Lesson%20Plans/Definition-Refugee-Persecution-Eligibiity-31aug10.pdf

4. Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Population Estimates and Projections. Retrieved from http://www.census.gov/content/dam/Census/library/publications/2015/demo/ p25-1143.pdf

5. Pereira, C., Larder, N., & Somerset, S. (2010). Food acquisition habits in a group of African refugees recently settled in Australia. Health & Place, 16(5), 934–941. doi:10.1016/j.healthplace.2010.05.007

6. Adekeye, O., Kimbrough, J., Obafemi, B., & Stack, R. (2014). Health literacy from the perspective of African immigrant youth and elderly: A PhotoVoice project. Journal of the Poor and Underserved, 25(4), 1730–1747. doi:10.1353/hpu.2014.0183

7. Vue, W., Wolff, C., & Goto, K. (2011). Hmong food helps us remember who we are: Perspectives of food culture and health among Hmong women with young children. Journal of Nutrition Education and Behavior, 43(3), 199–204. doi:10.1016/j.jneb.2009.10.011

8. Wilson, A., & Renhazo, A. (2014). Intergenerational differences in acculturation experiences, food beliefs, and perceived health risks among refugees from the Horn of Africa in Melbourne, Australia. Public Health Nutrition, 18(1), 176–188. doi:10.1017/S1368980013003467

75

 

9. Rondinelli, A. J., Morris M. D., Rodwell T. C., Moser K.S., Paida P., Popper S.T., & Brouwer K. C. (2011). Under- and over-nutrition among refugees in San Diego County, California. Journal of Immigrant and Minority Health, 13(1), 161–168. doi:10.1007/s10903-010-9353-5

10. Franzen, L., & Smith, C. (2009). Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite, 52(1), 173–183. doi:10.1016/j.appet.2008.09.012

11. Garnweidner, L. M., Terragni, L., Pettersen, K. S., & Mosdol, A. (2012). Perceptions of the host country’s food culture among female immigrants from Africa and Asia: Aspects relevant for cultural sensitivity in nutrition communication. Journal of Nutrition Education and Behavior, 44(4), 335–342. doi:10.1016/j.jneb.2011.08.005

12. Peterman, J. N., Silka, L., Bermudez, O. I., Wilde, P. E., & Rogers, B. L. (2011). Acculturation, education, nutrition education, and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. Journal of the American Dietetic Association, 111(9), 1369–1374. doi:10.1016/j.jada.2011.06.005

13. Tiedje, K., Wieland, M. L., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2014). A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States. International Journal of Behavioral Nutrition and Physical Activity, 11, 63. doi:10.1186/1479-5868-11-63

14. Anderson, L. C., Mah, C. L., & Sellen, D. W. (2015). Eating well with Canada’s food guide? Authoritative knowledge about food and health among newcomer mothers. Appetite, 91, 357–365. doi:10.1016/j.appet.2015.04.063

15. Mannion, C. A., Raffin-Bouchal, S., & Henshaw, C. J. (2014). Navigating a strange and complex environment: Experiences of Sudanese refugee women using a new nutrition resource. International Journal of Women’s Health, 16(6), 411–422. doi:10.2147/IJWH.S56256

16. Mulasi-Pokhriyal, U., Smith, C., & Franzen-Castle, L. (2012). Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9–18 years. Public Health Nutrition, 15(1), 176–185. doi:10.1017/S1368980011001649

17. Hrboticky, N., & Krondl, M. (1984). Acculturation to Canadian foods by Chinese immigrant boys: Changes in the perceived flavor, health value and prestige of foods. Appetite, 5(2), 117–126. doi:10.1016/S0195-6663(84)80031-8

76

 

18. Smith, C., & Franzen-Castle, L. (2012). Dietary acculturation and body composition predict American Hmong children’s blood pressure. American Journal of Human Biology, 24(5), 666–674. doi:10.1002/ajhb.22295

19. Wieland, M. L., Tiedje, K., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2015). Perspectives on physical activity among immigrants and refugees to a small urban community in Minnesota. Journal of Immigrant and Minority Health, 17, 263–275. doi:10.1007/s10903-013-9917-2

20. Franzen-Castle, L., & Smith, C. (2014). Environmental, personal, and behavioral influences on BMI and acculturation of second generation Hmong children. Maternal and Child Health Journal, 18(1), 73–89. doi:10.1007/s10995-013-1235-8

21. Diaz, H., Marshak, H. H., Montgomery, S., Rea, B., & Backman D. (2009). Acculturation and gender: Influence on healthy dietary outcomes for Latino adolescents in California. Journal of Nutrition Education and Behavior, 41(5), 319–326. doi:10.1016/j.jneb.2009.01.003

22. Liu, J. H., Chu, Y. H., Frongillo, E. A., & Probst, J. C. (2012). Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. Journal of Nutrition, 142(2), 298–305. doi:10.3945/jn.111.145516

23. Allen, M. L., Elliott, M. N., Morales, L. S., Diamant, A. L., Hambarsoomian, K., & Schuster, M. A. (2007). Adolescent participation in preventive health behaviors, physical activity, and nutrition: Differences across immigrant generations for Asians and Latinos compared with Whites. American Journal of Public Health, 97(2), 337–343.

24. Morris, M. D., Popper, S. T., Rodwell, T. C., Brodine, S. K., & Brouwer, K. C. (2009). Healthcare barriers of refugees post-resettlement. Journal of Community Health, 34(6), 529–538. doi:10.1007/s10900-009-9175-3

25. Arcan, C., Larson, N., Bauer, K., Berge, J., Story, M., & Neumark-Sztainer, D. (2014). Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and white adolescents. Journal of the Academy of Nutrition and Dietetics, 114(3), 375–383. doi:10.1016/j.jand.2013.11.019

26. Batis, C., Hernandez-Barrera, L., Barquera, S., Rivera, J. A., & Popkin, B. M. (2011). Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. Journal of Nutrition, 141(10), 1898–1906. doi:10.3945/jn.111.141473

77

 

27. Stang, J., Kong, A., Story, M., Eisenberg, M. E., & Neumark-Sztainer, D. (2007). Food and weight-related patterns and behaviors of Hmong adolescents. Journal of the American Dietetic Association, 107(6), 936–941.

28. Story, M., & Harris, L. J. (1989). Food habits and dietary change of Southeast Asian refugee families living in the United States. Journal of the American Dietetic Association, 89(6), 800–803.

29. Kim, L. P., Harrison, G. G., & Kagawa-Singer, M. (2007). Perceptions of diet and physical activity among California Hmong adults and youths. Preventing Chronic Disease, 4(4), A93.

30. Renzaho, A. M., McCabe, M., & Swinburn, B. (2012). Intergenerational differences in food, physical activity, and body size perceptions among African migrants. Qualitative Health Research, 22(6), 740–754. doi:10.1177/1049732311425051

31. Martin, D. C., & Yankay, J. E. (2012). Annual Flow Report 2012: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ ois_rfa_fr_2012.pdf

32. American Immigration Council. (2013). New Americans in North Carolina: The political and economic power of immigrants, Latinos, and Asians in the Tar Heel State. Retrieved from http://www.immigrationpolicy.org/sites/default/files/docs/ new_americans_in_north_carolina_2015.pdf

33. Refugee Council USA. (n.d.). The US Resettlement Program in North Carolina. Retrieved from http://www.rcusa.org/uploads/pdfs/WRD-2014/North-Carolina.pdf

34. Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. doi:10.1111/j.1365-2648.2007.04569.x

35. Colby, S., Morrison, S., & Haldeman, L. (2009). What changes when we move? A transnational exploration of dietary acculturation. Ecology of Food and Nutrition, 48, 327–343.

36. Franzen, L., & Smith, C. (2009). Differences in stature, BMI, and dietary practices between US born and newly immigrated Hmong children. Social Science & Medicine, 69(3), 442–450. doi:10.1016/j.socscimed.2009.05.015

37. Lv, N., & Brown, J. L. (2010). Chinese American family food systems: Impact of western influences. Journal of Nutrition Education and Behavior, 42(2), 106–114.

38. Hsieh, S., Klassen, A. C., Curriero, F. C., Caulfield, L. E., Cheskin, L. J., Davis, J. N., . . . Spruijt-Metz, D. (2014). Fast-food restaurants, park access, and insulin

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resistance among Hispanic youth. American Journal of Preventative Medicine, 46(4), 378–387. doi:10.1016/j.amepre.2013.12.007

39. Lopez, V., Corona, R., & Halfond, R. (2013). Effects of gender, media influences, and traditional gender role orientation on disordered eating and appearance concerns among Latino adolescents. Journal of Adolescence, 36(4), 727–736. doi:10.1016/j.adolescence.2013.05.005

40. Neumark-Sztainer, D., Croll, J., Story, M., Hannan, P. J., French, S. A., & Perry, C. (2002). Ethnic/racial differences in weight-related concerns and behaviors among adolescent girls and boys: Findings from Project EAT. Journal of Psychosomatic Research, 53(5), 963–974. doi:10.1016/S0022-3999(02)00486-5

41. Neumark-Sztainer, D., Wall, M, Haines, J, Story, M, & Eisenberg, M. E. (2007). Why does dieting predict weight gain in adolescents? Findings from project EAT-II: A 5-year longitudinal study. Journal of the American Dietetic Association, 107(3), 448–455.

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CHAPTER V

NUTRITION AND PHYSICAL ACTIVITY CHANGES, PERCEPTIONS,

CONCERNS AND INTERESTS WITH A DIVERSE GROUP OF NEWCOMER YOUTH

Abstract

Introduction: North Carolina ranks in the top ten nationally in refugee resettlement with

a central county one of the most diverse in the southeast. Newcomer youth are

understudied but have demonstrated rapid, negative acculturation. The objective of this

study was to explore diet, physical activity, and health perceptions, changes, and interests

of newcomer youth.

Methods: Participants (n=67) ages 12–17 were included who spoke English, Spanish,

French, Vietnamese, Burmese and/or Arabic. Paper and pencil surveys were translated

and read orally to students. Heights and weights were taken to calculate BMI. Data

analysis was conducted utilizing SPSS 20.0 and included frequency and bivariate

analysis. Dietary acculturation scores were calculated on a 9-point scale based on

reported intake of new, nontraditional foods upon arrival to the U.S.

Results: 31.5% of the students were overweight/obese. Of all the students, 45.8%

reported they believed their weight was “good” and 46.8% had tried to lose weight and

36.1% had tried to gain weight. Dietary acculturation scores varied by region (7.0 Central

America vs. 3.0 Middle East). An ANOVA comparison revealed that dietary

acculturation scores were marginally associated with BMI (p=0.057). Some food trends

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increased upon arrival (e.g., fruit and fruit juice, 1-2x/day to 3x/day; soda, rarely to

1-2x/day; and salty snacks, 1-2x/week to 1-2x/day). Reported frequencies for vegetables,

milk, meat, and legumes/beans/nuts remained consistent. With regard to consumption,

traditional vs. American foods 33.2% reported only traditional foods and 22.7% mostly

traditional foods. Over 85% (85.3%) had tried four or more new foods. The largest

factors influencing food choices included health (70.1%), taste (55.2%), religion (45.3%),

and convenience (44.6%). The lowest influences on food choices included TV (6.1%)

and friends (10.6%). ANOVA analysis revealed significant relationships between dietary

acculturation and the value of convenience (p=0.003) and observing Americans eat foods

(p=0.030). Students reported they wished to be more physically active (84.8%), they

would like the opportunity to play more sports (84.7%), and that physical activity

influenced their health (83.1%). In contrast, 41.5% believed diet influenced health, 62.5%

believed their diet could be healthier, and 56.7% believed they were healthy.

Conclusions: Students more heavily associate the benefits of physical activity with their

health than diet and would like the opportunity to play more sports. Dietary acculturation

is rapid and influenced by many factors. Overweight and obesity rates are concerning and

students report attempts to gain and lose weight.

Introduction

In 2013, 990,553 individuals became lawful residents in the U.S.1 Of these

individuals, 10.4% (103,191) were between 5 and 14 years of age and 16.7% (165,893)

were between the ages of 14 and 24.1 In addition to general immigration, 69,909 entered

the U.S. as refugees and 33.8% were under the age of 18 (23,647).2 Individuals entering

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the U.S. under refugee status, by the Immigration and Nationality Act 101(a)(42), must

be “unable or unwilling to return to his or her country of nationality because of

persecution or a well-founded fear of persecution on account of race, religion, nationality,

membership in a particular social group, or political opinion.”3

In addition to consistent, annual immigration rates (990,553 in 2013, 1,031,632 in

2012, and 1,062,040 in 2011), the ethnic makeup of the U.S. is projected by the Census

Bureau to rapidly change between 2014 and 2060 with immigration strongly impacting

these expected changes.1,4 The foreign-born population is estimated to grow by 85% and

foreign-born under 18 years of age is expected to increase by 29.8% between 2014 and

2060.4 As the makeup of the U.S. rapidly shifts over the next few decades, the health and

nutrition needs of these groups must be examined to support national, state, and local

health priorities and polices (e.g., Healthy People, Dietary Guidelines) that will address

the health and nutrition needs of an increasingly ethnically and culturally diverse

population. Incoming groups, particularly refugee groups, have not been well studied

despite demonstrated risks. Immigrant and refugee youth are especially understudied

despite their numbers.

Large generational disparities in dietary acculturation have been regularly

reported and frequently result in family tensions.5-15 A paradox appears to be occurring as

older generations attempt to maintain their traditional diets while youth rapidly adopt a

variety of unhealthful food behaviors (e.g., Sugar-sweetened beverages (SSB),

convenience and fast foods (FF)). Newcomer youth are quickly exposed to many new

foods as they attend school. School offers a new variety of foods—often convenience

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foods, but also milk, other sources of dairy, and local fruits and vegetables. As previously

cited, youth accept Western foods at faster rates. Improved nutrient status with adoption

of some foods (i.e., calcium found in dairy products) has been associated with increased

acculturation; however, increases in fat consumption, total calories, increases in BMI,

and adverse effects on blood pressure have also been reported.16-20 Less acculturated

newcomer youth report higher consumption of fruits and vegetables and diet quality.21-23

Not all ethnic groups acculturate at equal rates or with equal outcomes.23-25

In a study by Allen et al., Latino and Asian youth were compared over several

generations. Asian youth either maintained health behaviors or improved regarding diet

quality and physical activity, whereas Latino youth showed decreased diet quality over

time (e.g., decreases in fruit and vegetables, increases in sodas) but an increase in

physical activity.23 In a study by Arcan et al., Somali, Hispanic, Hmong, and white

adolescents were compared and shared diet trends low in fruits, vegetables, and dairy and

high fast food consumption, with Hispanic and Somali teens consuming the most fast

food.25 Time, taste, and convenience have been described as influencing factors in

increasing consumption of fast food and convenience foods in a study with Mexican,

Cambodian, Sudanese, and Somalian adolescents.13 In another study with Mexicans,

within one generation in the U.S., influence of the traditional diet was lost, suggesting

rapid change.26 These studies support findings from studies with caregivers, cited

previously, in which parents report their children request and desire Western foods, yet

also indicating that acculturation is complex and may vary distinctly between ethnic

groups and may result in positive and negative dietary changes.

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Adolescents play a more active role in shopping and preparing foods for the

family, and have more independence choosing or preparing their own foods, with

newcomer youth reporting more participation in food selection and preparation.10,19,27,28

Additionally, the role of adolescent newcomers as cultural brokers may increase their

influence on the family diet.29 Different cultures report differences in the power

adolescents hold, with mixed influence reported in African homes and less influence in

some Asian cultures.8,25,29,30 Adolescents demonstrate heightened sensitivity to peer

pressure, social expectations, and body image. Studies with African, Southeast Asian, and

Hispanic youth all report attempts to modify their diet or increase physical activity in

order to control their weight or “look/feel good.”10,21,25,27,29,30 Dieting in youth may occur

in contrast to generational differences in perception of weight with parents reporting

attempts to increase children’s weight, while youth report resistance.25,29 Many

adolescents report family members with chronic conditions, especially diabetes in

African and Southeast Asian groups; however, weight is rarely associated as a risk factor

(sugar is most commonly identified and associated with diabetes).

In summary, dietary acculturation occurs rapidly in youth, varies between ethnic

groups, and may result in healthful and/or risky dietary choices and if not improved will

likely lead to adverse health outcomes. Newcomer adolescents play a role in shopping

and preparing food and also demonstrate body image concerns as well as reports of

dieting or increased activity to modify body weight. Literature regarding attitudes,

knowledge, perceptions, and interests of newcomer adolescents is limited despite the

potential health and nutrition risks associated with acculturation as “new” foods are often

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convenience and fast foods. The objective of this study was to examine nutrition and

health knowledge, changes (e.g., food choices, physical activity), perceptions, and

interests of newcomer youth.

Methods

Study Design

Surveys were conducted between April and May of 2015 during high school and

middle school Physical Education (P.E.), Health, and Art classes at a school for

newcomer youth in North Carolina. Written parental consent was obtained in the primary

language via recruitment packets sent home through the P.E., Health, and Art classes as

well as written and/or oral informed student assent in their primary language prior to any

data collection. An interpreter was available to students to answer any questions as well

as assist in obtaining oral and/or written assent. Anthropometric measurements

(height/weight) were also obtained for each student. The study was approved by the

institutional review board at The University of North Carolina at Greensboro and the

school district’s Research Review Committee prior to recruitment and data collection.iii

Survey Development

The survey was developed specifically for this study and was content validated by

experts (n=3) in the field of immigrant and refugee nutrition and health and/or family-

focused nutrition (see Appendix I). Survey sections included specific questions regarding

(a) sociodemographic information; (b) dietary intake trends pre-/post-arrival to the U.S.

for fruits, vegetables, fruit juice, milk, soda, meat, non-meat proteins (e.g., legumes,

                                                            iii This description of the school is the wording required in agreement with the school district for confidentiality purposes for research conducted within the school system.

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nuts), salty snacks and sweets, and physical activity; (c) dietary acculturation and

perceptions of U.S. foods and traditional food access; (d) home food environment

(selection, influence, preparation); (e) influencing factors on diet choices (e.g., time,

taste, religion, TV); (f) health literacy and nutrition/weight/physical activity concerns and

needs; and (g) an open-ended section for students regarding diet and health. The survey

was translated and offered in a total of six languages including English, Spanish, Arabic,

French, Vietnamese, and Burmese.

Site Description

The study was conducted at a school for newcomer youth in North Carolina that

provides a specialized environment for students during their first year in the U.S. North

Carolina ranked in the top ten in 2012 for refugee resettlement and receives high numbers

of immigrants annually.8 North Carolina was home to 749,426 immigrants in 2013 with

31.9% naturalized U.S. citizens including high numbers of Asian and Latin American

immigrant populations.31 There were approximately 350,000 unauthorized immigrants in

North Carolina in 2013.32 Also, there were 2,110 refugees who arrived in North Carolina

in 2012 most of whom initially resettled in Charlotte, Durham, Greensboro, High Point,

New Bern, and Raleigh.33 The largest refugee populations in North Carolina include the

following countries of origin: Myanmar, Bhutan, Iraq, Cuba, Eritrea, Democratic

Republic of the Congo, and the Sudan.33

To meet diverse population needs, the school employs part-time and fulltime

onsite bilingual community liaisons who help school staff communicate with students

and families. The school also has an onsite fulltime social worker in addition to a

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guidance counselor. The school provides initial placement testing, instruction that meets

grade level standards, and an opportunity for specialized instruction to educational

procedures and culture in the U.S. The school also coordinates efforts with the local

health (e.g., County Health Department, local pediatric community clinics) and social

service organizations in support of students and families (e.g., immunization

requirements, clothing, medical, and dental needs).

Recruitment and Inclusion Criteria

All students in P.E., Health, and Art classes between the ages of 12 and 17 who

spoke English, Spanish, Arabic, French, Vietnamese, or Burmese were provided with a

recruitment packet that included a study flyer as well as two parent consent forms (see

Appendices F and G). These languages were dependent upon the school’s current ethnic

groups as well as available staff for translation and interpretation. Packets were

distributed by the P.E., Health, and Art teachers at the school. The packets were collected

on a regular basis over a four-week period during April 2015. Students who returned

packets with parental consent (written) and provided assent (oral and written; see

Appendix H) participated in the survey and/or focus groups.

Confidentiality, Translation, and Interpretation Services

Community liaisons (Burmese n=1, Vietnamese n=1, Arabic n=1, Spanish n=1)

and non-school staff interpreters/translators (Spanish n=3, Arabic n=1 and Frenchiv n=4)

were trained by the principal investigator regarding confidentiality and the scope of the

research project within IRB requirements of The University of North Carolina for

                                                            iv French language services were currently unavailable at the school.

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community partners assisting with interpretation and translation of research data. Each

community liaison and community interpreter/translator provided written documentation

acknowledging confidentiality of participants and data as well as their independent

choice to participate in this research study.

Community liaisons staffed by the school translated Arabic, Burmese, and

Spanish study documents (flyer, parental consent, student assent, surveys). The school’s

community liaisons’ professional duties included regularly translating school documents

and communications between the school and families. French and Vietnamese study

documents were translated by bilingual, international local college students (e.g., French-

student from Ivory Coast at The University of North Carolina at Greensboro and the

Vietnamese student from Vietnam who attended the University of North Carolina at

Chapel Hill).

Interpretation services during survey collection (assent, oral review of surveys,

answering student questions) were primarily provided by community liaison staff at the

school (Arabic, Vietnamese, Burmese, and Spanish) with additional trained community

members to assist in Spanish, Arabic, Vietnamese, and French services. Interpretation

services were provided during the student assent process as well as to review the survey

orally and answer questions throughout the survey. Open-ended questions were also

translated into English for data analysis by the various school staff and community

members previously described.

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Survey Data Collection

Surveys were given during P.E., Health, and Art class time in an unused

classroom or the school cafeteria. Each survey distribution lasted approximately 45

minutes. Students were divided by language and an interpreter was present with each

student group to orally review student assent and the survey and to answer questions.

Several research assistants, in addition to the primary investigator, were present to assist

with survey distribution, answer any questions the interpreters had regarding the survey

or student’s questions, as well as to obtain assent for each student. Some younger

students (middle school students) took two sessions to complete the survey. Most high

school students completed the surveys during one session (one 45-minute class period). A

total of 87 surveys were given, 20 surveys were discarded, and 67 surveys were available

for analysis. Surveys not included were discarded for the following reasons: (a) student

did not record their date of birth and their age could not be verified to fit study inclusion

criteria, (b) the student was over the age of 17, (c) the survey was incomplete and the

student could not be located to complete the survey on a follow-up day, (d) or students

sent to the English group by school staff demonstrated lack of language proficiency

during the assent process and could not ethically be included. (To reduce student

embarrassment rather than interrupting their assent, the student was allowed to complete

the survey, which was marked after it was turned in by the student as “non-language

proficient” to be discarded upon analysis.)

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Anthropometric Measurements

After completion of the survey, student height and weight were taken by a

research assistant of the same gender in a semiprivate area within the classroom/

cafeteria. Prior to having their height taken students were asked to remove their shoes

(students were verbally given the option to decline removing shoes). Students with

religious head coverings were not asked to remove their head coverings prior to having

their height taken. Height was taken using a stadiometer and was recorded to the nearest

tenth of a centimeter. Weight was taken with a calibrated digital scale and was recorded

to the nearest tenth of a kilogram. Each student’s measurements were recorded in the

indicated area on the final page of the survey to ensure BMI data were correctly

identified.

Quantitative Data Analysis

Closed-ended question survey data (N=67) were analyzed using IBM SPSS

software 20.0. Data analysis focused primarily on descriptive statistics of survey

responses as well as bivariate analysis. A dietary acculturation score was developed and

calculated specifically for this project and utilized in both descriptive and bivariate

analysis (see Table 5.1). The scores ranged from 0 to 9, with larger numbers indicating

greater dietary change and 0 indicating no reported dietary change.

Students’ date of birth, survey/anthropometric measurement date, height (cm) and

weight (kg) were entered into the Center for Disease Control and Prevention BMI

Calculator Tool for Schools to calculate BMI.34 Descriptive analysis was completed on

all closed-ended quantitative survey questions (1-46) and focused on frequencies,

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median, mode, and mean ± standard deviation (Survey Variables; see Appendix J).

Bivariate analysis focused on relationships between gender, refugee camp experience,

English at home, region of origin (e.g., Middle East, Africa, Latin America/Caribbean,

and Southeast Asia), BMI, dietary acculturation scores, and various reported diet,

physical activity, and diet-related perceptions, interests, and behaviors.

Table 5.1 Dietary Acculturation Score Calculation

Survey Question

Survey Responses and Scoring

Max Score Per Question

12) I have tried new foods in the U.S.

Not yet, and I do not want to

Not yet, but I would like to

A Few

(1–3 different new foods)

Some

(4–5 different new foods)

Many!

(more than 5 different new foods)

New Foods Score:

0 0.5 1 2 3 3

13) I have tried new beverages in the U.S.

Not yet, and I do not want to

Not yet, but I would like to

A Few

(1–3 different new foods)

Some

(4–5 different new foods)

Many!

(more than 5 different new foods)

New Beverages Score:

0 0.5 1 2 3 3

29) We eat at home:

We eat almost only traditional foods

We eat mostly traditional foods but we do try new American foods.

We have meals with both traditional foods and American foods

We eat mostly American foods now

Home Food Environment Score:

0 1 2 3 3

Total Max Dietary Acculturation Score 9

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Independent samples t-tests utilized dichotomous sociodemographic variables

(e.g., gender m/f, refugee Camp experience y/n, English use at home y/n, and BMI

normal vs. overweight (ov)/obese (ob)) to examine associations with dietary acculturation

scores. Paired samples t-tests were utilized to identify significant changes in food

category consumption between pre-U.S. diet and physical activity trends and diet and

physical activity trends upon arrival to the U.S. Region of origin and BMI categories

(underweight, normal, overweight, obese) vs. dietary acculturation scores were analyzed

using a one-way ANOVA.

Due to the sample size (n=67), Fischer’s exact test was selected (vs. Pearson’s

Chi Square) for sufficient power to examine relationships between sociodemographic

variables and dietary and health related perceptions, behaviors, knowledge interests, and

needs. To fit the dichotomous variable parameters of Fischer’s exact test, four

sociodemographic variables (gender m/f, Refugee Camp experience y/n, English use at

home y/n, and BMI status normal vs. ov/ob) were utilized and questions regarding dietary

choices (survey questions 31 a-k, and survey questions 32-46) were recoded into

dichotomous variables. Survey questions 31 a-k, which included influence on dietary

choices (e.g., taste, religion), were recoded into two categories for analysis: (a) not

important, and (b) somewhat/very important. In comparison, survey questions 32-46

regarding concerns, knowledge, interests, and needs (e.g., I think my diet could be

healthier, I think what I eat affects my health) were recoded into two categories for

analysis: (a) no/disagree, and (b) maybe/yes. No other survey variables were modified or

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recoded. Lastly, all bivariate analysis followed the following criteria to identify statistical

significance: *p<0.5, **p<0.10, ***p<0.01.

Qualitative Survey Data Analysis

Open-ended survey questions 47-50 (e.g., list healthy foods, unhealthy foods,

topics on which you want more information) were reviewed for themes using open-ended

content analysis as outlined by Elo and Kyngäs.35 Results were quantified and organized

in order of decreasing frequency.

Results

The final sample of surveys analyzed (N=67) was comprised primarily of Spanish,

English, and Arabic surveys (33.8%, 25%, and 19%, respectively) with French, Burmese,

and Vietnamese making up the smallest percentages (10.3%, 5.9%, and 5.9%,

respectively; see Table 5.2). These languages represented a diverse group of students

with 35 countries of origin (n=35 by the student’s birthplace, n=33 for their mothers).

The sample contained 55.2% female and 44.8% male students with a mean age of 14.9 ±

1.7 years and a mean residence of 0.77 ± 0.98 years in the U.S. Most students attended

school prior to arrival (94.1%) and the mean length of previous school was 7.54 ± 2.41

years. Of those students reporting previous residence in a refugee camp (n=20), the

average length of stay was 8.45 ± 6.61years (range 16.97). It should be noted that the

Arabic survey missed the question regarding refugee camp experience. It is likely many

of the Arabic surveys (primary countries of origin included Iraq and the Sudan) would

have also included a refugee camp experience.

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Table 5.2

Newcomer Youth Demographics (N=67)

Demographic Variable n (%)

Survey Distribution by Language (Survey Language)

Spanish English Arabic French Vietnamese Burmese

23 (33.8) 17 (25)

13 (19.1) 7 (10.3) 4 (5.9) 4 (5.9)

Number of languages spoken

1 Language 2 Languages 3+ Languages

28 (41.8) 24 (35.8) 11 (22.4)

Gender

Male Female

30 (44.8) 37 (55.2)

Age (Mean)

14.92 ± 1.735 years

Time in the U.S. (Mean)

0.77 ± 0.98 years

Lived in Refugee Camp*

Yes No

20 (37) 33 (61.1)

Time in Refugee Camp (Mean)

8.45 ± 6.61 (range 16.97)

Major Regions Represented

Africa Latin America/Caribbean Southeast Asia Middle East Other/Missing

24 (35.3) 17 (25)

12 (17.6) 9 (13.2) 6 (8.8)

Number of countries of origin

Student (birth) Mother (birth)

35 (52.2) 33 (49.3)

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Table 5.2

Cont.

Demographic Variable n (%)

Top countries of origin (birth country)

El Salvador Iraq U.S. Vietnam Sudan Thailand

9 (13.4) 7 (10.4) 6 (9.0) 4 (6.0) 3 (4.5) 3 (4.5)

Education prior to U.S.

Yes No

64 (94.1) 4 (5.9)

Mean Years of Education Pre-U.S.

7.54 ± 2.41

*Arabic survey question for refugee camp was missing, n=14 surveys were listed as missing in this category, 13 surveys were given in Arabic.

Survey questions regarding household characteristics revealed most families

(57.4%; see Table 5.3) did not use English at home and a total of 22 languages were

listed as primary languages for the student (over half of the students spoke more than one

language; see Tables 5.2 and 5.3). The mean household size was 6.21 ± 2.19 and the

mean number of siblings was 3.55 ± 2.41.

Survey questions regarding household characteristics revealed most families

(57.4%; see Table 5.3) did not use English at home and a total of 22 languages were

listed as primary languages for the student (over half of the students spoke more than one

language; see Tables 5.2 and 5.3). The mean household size was 6.21 ± 2.19 and the

mean number of siblings was 3.55 ± 2.41. Anthropometric data revealed only one student

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out of 67 to be underweight, 31.5% (n=17) was found to be overweight and/or obese, and

66.7% (n=36) of the sample was found to be of normal BMI (see Table 5.4 and Figure

5.1).

Table 5.3

Household Characteristics

Characteristic n (%)

Speaks English at home?

Yes No

29 (42.6) 39 (57.4)

Primary Language Spoken at Home (Top 4)

Spanish Arabic Somalian Swahili

22 (32.8) 11 (16.4) 4 (6.0) 4 (6.0)

Total Unique Languages Spoken

22

Mean Household Size

6.21 ± 2.19

Mean Number siblings

3.55 ± 2.41

Survey questions regarding household characteristics revealed most families

(57.4%; see Table 5.3) did not use English at home and a total of 22 languages were

listed as primary languages for the student (over half of the students spoke more than one

language; see Tables 5.2 and 5.3). The mean household size was 6.21 ± 2.19 and the

mean number of siblings was 3.55 ± 2.41. Anthropometric data revealed only one student

out of 67 to be underweight and 31.5% (n=17) was found to be overweight and/or obese,

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and 66.7% (n=36) of the sample was found to be of normal BMI (see Table 5.4 and

Figure 5.1). Furthermore, rates of overweight and obesity were not distributed equally,

and female students had higher rates of overweight and obesity in comparison to male

students (37% vs. 25%, respectively; see Figure 5.2). BMI data were also separated per

major geographic region with differences in ov/ob trends per group (see Table 5.5, Figure

5.3).

Table 5.4

BMI Data (n=54)

BMI Category

Males n (%)

Females n (%)

Overall n (%)

Underweight 0 (0) 1 (3.0) 1 (1.9)

Normal Weight 15 (71.4) 21 (63.6) 36 (66.7)

Overweight 4 (19.0) 4 (12.1) 8 (14.8)

Obese 2 (9.5) 7 (21.2) 9 (16.7)

Figure 5.1. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12-17.

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Figure 5.2. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12-17 by

Gender.

Table 5.5

BMI Data by Geographic Region

Region

Sample n

Normal n (%)

OV/OB n (%)

Southeast Asia 11 9 (81.8) 2 (18.2)

Middle East 8 5 (62.5) 3 (37.5)

Africa 18 13 (76.5) 4 (23.5)

Central America 14 7 (50) 7 (50)

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Figure 5.3. Prevalence of Overweight and Obesity in Newcomer Youth Ages 12-17 by

Geographic Region.

Lifestyle behaviors related to weight status revealed a variety of perceptions

regarding pre- and post-arrival diet quality and physical activity (PA) levels (e.g., 36%

perceived they were more active Pre-U.S., and 40.2% perceived they were more active

post-arrival to the U.S.). Perceptions of pre-arrival diet quality demonstrated the highest

trend with over half of students reported their diet prior to the U.S. to be healthy (see

Table 5.6).

In addition to the overall perceptions to diet and physical activity, students were

asked specific questions regarding the frequency of consumption of food groups and

physical activity. Significant increases between pre- and post-arrival to the U.S. were

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identified using paired samples t-tests for the consumption of milk, fruit juice, soda, and

meat (p=0.009, p=0.002, p=0.026, and p=0.010, respectively; see Table 5.7).

Table 5.6

Perceptions of Diet and Physical Activity Pre-/Post-Arrival to the U.S.

Survey Statement

Survey Responses n (%)

I think my eating before coming to the United States was:

Less Healthy Healthy Healthier than now

13 (20.3) 37 (57.8) 14 (21.9)

Now that I am in the U.S. I think my eating is:

Less Healthy than before Similar to before Healthier than before

17 (27.0) 24 (38.1) 22 (34.9)

I think before I came to the U.S.:

Less physically active than now Similar level of activity to now More physically active than now

17 (27.0) 23 (36.5) 23 (36.5)

Now that I am in the U.S. I think I am:

Less Physical Active Similar in my physical activity More physically active

20 (32.3) 17 (27.4) 25 (40.3)

In addition to the overall perceptions to diet and physical activity, students were

asked specific questions regarding the frequency of consumption of food groups and

physical activity. Significant increases between pre- and post-arrival to the U.S. were

identified using paired samples t-tests for the consumption of milk, fruit juice, soda, and

meat (p=0.009, p=0.002, p=0.026, and p=0.010, respectively; see Table 5.7).

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Table 5.7

Paired Samples t-tests Comparison of Food Patterns: Pre- and Post-U.S. Arrival

Food Category: “I ate/eat” “I drank/drink”

Pre-U.S. Mean Frequency§ of consumption

(SD)

U.S. Mean Frequency§ of consumption

(SD)

t

p

Fruits 4.95 (1.69) 5.35 (1.57) -1.881 0.064

Vegetables 4.92 (1.59) 5.27 (1.43) -1.464 0.148

Milk 4.76 (2.15) 5.52 (1.63) -2.703 0.009**

Fruit Juice 4.52 (1.71) 5.23 (1.65) -3.220 0.002**

Soda 4.00 (1.85) 4.48 (1.91) -2.293 0.026*

Meat (like chicken, fish, eggs) 4.58 (1.73) 5.09 (1.3) -2.671 0.010**

Beans or legumes 4.68 (1.65) 4.38 (1.9) 1.574 0.121

Salty snacks like chips or crackers

4.03 (1.88) 4.38 (1.67) -1.536 0.130

Sweet foods like cookies or cake 4.61 (1.7) 4.74 (1.74) -.723 0.473

Active for fun 4.95 (1.83) 4.68 (1.92) 1.029 0.307 §1 = Never; 2 = Rarely; 3 = Monthly (1-2x); 4 = Weekly (1-2x) 5= Weekly (3-5x); 6 = Daily (1-2x); 7 = Daily (3+) *p<0.5, **p<0.10, ***p<0.01

In addition to these specific changes, overall dietary acculturation was assessed

and found to be high with only 14.7% of students reporting that they had not tried any

new foods and 22.14% had not tried any new beverages (see Table 5.8). Access to

traditional foods was perceived to be fairly good (38.2% easy to find, 30.9% most easy,

some hard) and perceptions of the taste of traditional foods in the U.S. varied with some

reporting taste to be similar (35.3%), better (25%), or not as good (23.5%). American

food was perceived by most to be healthy or very healthy (44.1% and 36.8%,

respectively).

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Table 5.8

Dietary Acculturation (Traditional and American) and Perceptions of Food (Access,

Taste)

Survey Question/Statement and Responses n (%)

I have tried new foods in the U.S.

Not yet, and I do not want to Not yet, but I would like to A few (1-3 new/different foods) Some (4-5 different/new foods) Many! (More than 5 different/new foods)

4 (5.9) 6 (8.8)

22 (32.4) 14 (20.6) 22 (32.4)

I have tried new Beverages in U.S.

Not yet, and I do not want to Not yet, but I would like to A few (1-3 new/different foods) Some (4-5 different/new foods) Many! (More than 5 different/new foods)

5 (7.4) 10 (14.7) 27 (39.7) 14 (20.6) 12 (17.6)

I think American food is:

Unhealthy Healthy Very Healthy

13 (19.1) 30 (44.1) 25 (36.8)

When I eat my traditional foods in the U.S. they taste:

Not as good Similar to before Better I am not sure

16 (23.5) 24 (35.3) 17 (25.0) 11 (16.2)

Finding the traditional foods I ate before I came to the U.S. is:

Easy for most foods Easy for some foods but harder for others Hard for most foods I am not sure

16 (38.2) 21 (30.9) 9 (13.2) 12 (17.6)

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Dietary acculturation scores calculated from responses regarding incorporation of

new foods, beverages, and meals at home were found to vary between regions (e.g.,

Mean dietary acculturation for Africa was found to be 3.77 ± 1.97 in contrast to 5.29 ±

1.65 in the Middle East), although not significantly (see Table 5.9, Figure 5.4).

Table 5.9

Dietary Acculturation Scores by Region, Gender, English Use, and BMI (n=60)

Mean Mode Median

Overall Scores 4.26 ± 1.99 4.0 4.0

Scores by Geographic Region

Southeast Asia 4.71 ± 1.91 6.0 5.5

Middle East 5.29 ± 1.65 6.0 6.0

Africa 3.77 ± 1.97 3.0 3.25

Central American/Caribbean 3.91 ± 2.11 7.0 4.0

Scores by BMI Category Status

Underweight 1.0 1.0 1.0

Normal 4.10 ± 1.91 4.0 4.0

Overweight 4.63 ± 2.67 3.0 3.5

Obese 5.78 ± 1.73 7.0 6.0

Scores by English status

Yes (speaks at home) 4.03 ± 1.98 3.0 4.0

No (speaks at home) 4.59 ± 1.99 4.0 4.0

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Figure 5.4. Distribution of Dietary Acculturation Scores of Newcomer Youth Ages 12-

17.

A one-way ANOVA revealed a marginally significant relationship between

dietary acculturation and BMI (p<0.057; see Table 5.10) with a positive trend between

dietary acculturation and BMI (e.g., ob/ob adolescents had a mean dietary acculturation

score of 5.23 ± 2.23 vs. 4.09 ± 1.91 of participants with a normal BMI). No significant

differences were identified in dietary acculturation between geographic regions.

Table 5.10

ANOVA Results: Sociodemographic Characteristics vs. Dietary Acculturation Scores

Sociodemographic Variables

Variation

df

Mean Square

F

Sig

Geographic Region Within groups 3 7.204

1.876 0.144 Between groups 58 3.840

BMI Category Within groups 3 10.783

2.678 0.057 Between groups 50 4.027

Note. Statistically significant differences are indicated *p<0.5, **p<0.10, ***p<0.01.

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No significant relationships were revealed between dietary acculturation scores

and gender, refugee camp experience, BMI status, or use of English at home (see Table

5.11).

Table 5.11

Sociodemographic Characteristics vs. Mean Dietary Acculturation Scores

Sociodemographic Variables

Categories

Number Samples

M

SD

t

df

Sig (2-tailed)

Gender Male 30 4.43 1.95

0.606 63.24 0.547 Female 37 4.14 2.05

English at Home Yes 39 4.03 1.98

-1.152 60.23 0.254 No 29 4.59 1.99

Refugee Camp Yes 20 4.03 1.82

-0.167 51.00 0.878 No 33 4.12 2.15

BMI Status (n vs. ov/ob)

Yes 36 4.10 1.91 -1.920 51.00 0.060

No 17 5.24 2.23

Note. Independent samples t-test performed. Statistically significant differences are indicated *p<0.5, **p<0.10, ***p<0.01

Another indicator of dietary acculturation (and a factor used in calculating dietary

acculturation scores) was the description of consumption of traditional meals at home.

One-third (33.3%) reported only traditional foods at home, 22.7% reported mostly

traditional foods at home, and 40.9% reported traditional American foods at home (see

Table 5.12). Most students reported their mothers prepare meals (59.7%) and that most of

the food selection is a combination of adults’ and the students’/siblings’ preferences

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(60%), and eating as a family was found to be important with 67.2% reporting they

usually eat together and 20.9% reporting it is important but they are unable to do so.

Table 5.12

Food Selection, Preparation, and Home Food Environment

Survey Statement/ Question and Responses n (%)

Who chooses what you eat at home?

We eat what my parents or grandparents prefer We eat what I and/or my siblings want We eat both foods my parents and me and/or my siblings want

11 (16.9) 14 (21.5) 39 (60)

Who prepares the food?

My mom does most of the cooking My dad does most of the cooking My grandmother does most of the cooking I cook most of our meals myself Different people cook

40 (59.7) 3 (4.5) 1 (1.5) 4 (6.0)

19 (28.4) We eat at home:

We eat almost only traditional foods Both traditional foods and American foods Mostly American foods now Mostly traditional foods, do try American foods

22 (33.3) 27 (40.9) 2 (3.0)

15 (22.7) Eating at home as a family:

Eating together as a family is a very important part of the day and we eat together We don’t usually eat together as a family We can’t eat together as a family because of work and schedules but it is important to eat as a family

45 (67.2) 8 (11.9)

14 (20.9)

Students and their siblings have influence over the meals served in the home and

many different factors influence their food choices. The highest reported factors include

preferences based on the perceived healthfulness of the food (70.1%), the taste (55.2%),

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meeting religious criteria (45.3%), as well as convenience (44.6%), culture (41.5%), and

family influence (39.4%; see Table 5.13). The lowest ranked factors included TV

advertising (6.1%) and friends (10.6%).

Table 5.13

Influencing Food Choices

Survey Responses

Not Important

Somewhat Important

Very Important

Survey Questions* n (%) n (%) n (%)

Health—I want to eat things that are good for me

4 (6.0) 16 (23.9) 47 (70.1)

Taste—it has to taste good to me 10 (14.9) 20 (29.9) 37 (55.2)

Religion—the food has to be allowed by my religion

31 (48.4) 4 (6.3) 29 (45.3)

Convenience—is it easy to get 13 (20.0) 23 (35.4) 29 (44.6)

Culture—familiar to me or that my community/culture eats

17 (26.2) 21 (32.3) 27 (41.5)

Family—if they want me to eat it I will 20 (30.3) 20 (30.3) 26 (39.4)

Cost—it does not cost a lot of money 13 (20.0) 28 (43.1) 24 (36.9)

Time—is it fast to make or get 12 (19.4) 31 (50.0) 19 (30.6)

U.S. Foods—I see American’s eating the food, so I try it/eat it

24 (35.8) 29 (43.3) 14 (20.9)

Friends—my friends eat the food so I try it/eat it

28 (42.7) 31 (47.0) 7 (10.6)

TV—I saw the food on TV so I try it/eat it

34 (51.5) 28 (42.4) 4 (6.1)

*Listed in decreasing order of importance

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Influencing factors on food choices were also compared to dietary acculturation

scores using a one-way ANOVA. Dietary acculturation scores were significantly

associated with convenience and observation of Americans eating foods influences on

selecting foods (p=0.003, p=0.030; see Table 5.14). Participants who reported

convenience and cost as influencing their food choices had lower mean dietary

acculturation scores (e.g., 3.94 ± 1.9 vs. 5.92 ± 1.5 for value of convenience, and 3.83 ±

2.0 vs. 5.10 ± 1.73 for observation of Americans eating foods).

Table 5.14

ANOVA Results: Influencing Factors on Dietary Choices vs. Dietary Acculturation

Scores

Sociodemographic Variables

Source of Variation

df

Mean Square

F

Sig

Health—I want to eat things that are good for me

Within groups 2 2.548 0.632 0.535

Between groups 64 4.031

Taste—it has to taste good to me

Within groups 2 6.792 1.742 0.183

Between groups 64 3.899

Religion—the food has to be allowed by my religion

Within groups 2 1.081 0.266 0.767

Between groups 61 4.067

Convenience—is it easy to get Within groups 2 21.725

6.457 0.003** Between groups 62 3.365

Culture—familiar to me or that my community/culture eats

Within groups 2 5.765 1.468 0.238

Between groups 62 3.926

Family—if they want me to eat it I will

Within groups 2 3.408 0.843 0.435

Between groups 63 4.042

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Table 5.14

Cont.

Sociodemographic Variables

Source of Variation

df

Mean Square

F

Sig

Cost—it does not cost a lot of money

Within groups 2 2.396 0.587 0.559

Between groups 62 4.079

Time—is it fast to make or get Within groups 2 8.082

2.171 0.123 Between groups 59 3.723

U.S. Foods—I see American’s eating the food, so I try it/eat it

Within groups 2 13.690 3.717 0.030*

Between groups 64 3.683

Friends—my friends eat the food so I try it/eat it

Within groups 2 1.939 0.474 0.625

Between groups 63 4.088

TV—I saw the food on TV so I try it/eat it

Within groups 2 10.392 2.721 0.074

Between groups 63 3.820 Note. Survey questions listed in order of decreasing frequency interest/agreement, statistically significant differences are indicated *p<0.5, **p<0.10, ***p<0.01

In addition, Fischer’s exact test was utilized to examine sociodemographic

variables on influencing factors on food choices. Perception of convenience was

significantly associated with gender (p=0.052; see Table 5.15) with convenience more

likely to determine food choices with female students (e.g., 88.6% of females reported

convenience as somewhat or very important in comparison to 69% of males). Perception

of religion, culture, family, time, American consuming foods, and friends were

significantly greater for students who reported having lived in a refugee camp (p=0.033,

p=0.051, p=0.029, p=.032, p=0.005, and p=0.008, respectively). Use of English at home

was not significantly associated with food choices. BMI category was significantly

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associated with taste and cost (p=0.010 and p=0.009, respectively) with overweight and

obese students more likely to report taste as important, and cost as unimportant.

Table 5.15

Fischer’s Exact Test Results: Sociodemographic Variables vs. Influencing Factors on

Food Choices

Significance (p values) by

Sociodemographic Variables

Survey

Questions

Gender (M/F)

Refugee camp (Y/N)

English at home (Y/N)

BMI Category

(n vs. ov/ob)

Health—I want to eat things that are good for me

0.596 0.501 0.585 0.218

Taste—it has to taste good to me 0.549 0.058 0.472 0.010**

Religion—the food has to be allowed by my religion

0.267 0.033* 0.590 0.543

Convenience—is it easy to get 0.052* 0.322 0.571 0.412

Culture—familiar to me or that my community/culture eats

0.577 0.051* 0.543 0.547

Family—if they want me to eat it I will

0.589 0.029* 0.178 0.452

Cost—it does not cost a lot of money

0.543 0.073 0.429 0.009**

Time—is it fast to make or get 0.449 0.032* 0.279 0.622

Seeing Americans eat the food 0.508 0.005** 0.524 0.339

Friends—my friends eat the food so I try it/eat it

0.309 0.008** 0.274 0.074

TV—I saw the food on TV so I try it/eat it

0.529 0.301 0.586 0.127

*Survey questions listed in order of decreasing frequency interest/agreement, ** statistically significant differences are indicated *p<0.5, **p<0.10, ***p<0.01

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Students also reported many strong interests and perceived needs with physical

activity with 84.8% reporting they would like to be more active, play more sports

(84.7%) and that being physically active helps them to be healthy (83.1%; see Table

5.16). In addition, students reported dietary concerns (62.5%) and interest in receiving

nutrition education (77.6%). Moreover, approximately half of the students (56.9%)

reported they would like for their family to receive nutrition education and approximately

half (50.8%) reported they were worried about the health of a family member. With

regards to weight status, only 36.1% reported their weight to be “good” and 46.8% had

tried to lose weight. In addition, 45.8% reported people talk to them about their weight,

with their parents being the most frequently reported individuals (48.3% mom, 17.2%

dad, 6.9% mom and dad).

Table 5.16

Health, Diet, Weight Interests, Attitudes, Knowledge, Concerns

Survey Questions/Statements

Survey Responses

No/ I Disagree

Not Sure, Maybe

Yes/ I Agree

n (%) n (%) n (%)

I would like to be more active 1 (1.5) 9 (13.6) 56 (84.8)

I would like the opportunity to play more sports

2 (3.4) 6 (10.2) 50 (84.7)

I think being physically active helps me to be healthy

2 (3.1) 9 (13.8) 54 (83.1)

I would like to learn more about how food affects my health

5 (7.5) 10 (14.9) 52 (77.6)

I think my diet could be healthier 5 (7.8) 19 (29.7) 40 (62.5)

I think I am healthy 5 (7.5) 24 (35.8) 38 (56.7)

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Table 5.16

Cont.

Survey Questions/Statements

Survey Responses

No/ I Disagree

Not Sure, Maybe

Yes/ I Agree

n (%) n (%) n (%)

I think my family needs to learn what foods are healthy in the U.S.

7 (10.8) 21 (32.3) 37 (56.9)

I would like to exercise with only other boys/girls

6 (9.1) 24 (36.4) 36 (54.5)

I am worried about the health of someone in my family

16 (24.6) 16 (24.6) 33 (50.8)

My family talks to me about my weight 17 (28.8) 15 (25.4) 27 (45.8)

I have tried to lose weight 16 (25.8) 17 (27.4) 29 (46.8)

I think my weight is good 14 (23.0) 25 (41.0) 22 (36.1)

I think what I eat affects my health 10 (15.4) 28 (43.1) 27 (41.5)

I would like my family to learn how to cook American foods

13 (20.0) 25 (38.5) 27 (41.5)

Health, diet, weight interests, attitudes, knowledge, and concerns were also

compared to dietary acculturation scores using a one-way ANOVA. No significant

relationships were observed. Health, diet, weight interests, attitudes, knowledge, and

concerns were also compared to gender, refugee camp experience, using English at home,

and BMI status using Fischer’s exact test. One significant relationship was identified

between BMI status and body image (“I think my weight is good”; p=0.01; see Table

5.17). Students in the normal BMI were most likely to report a positive body image in

comparison to ov/ob students (85.7% vs. 56.3%).

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Table 5.17

Fischer’s Exact Test Results: Sociodemographic Variables vs. Health Literacy, Concerns

and Perceptions, Nutrition, and Physical Activity Needs and Interests

Significance (p values) by Sociodemographic Variables

Survey

Questions

Gender (M/F)

Refugee camp (Y/N)

English at home (Y/N)

BMI Category

(n vs. ov/ob)

I would like to be more active 0.554 0.392 0.561 0.686

I would like the opportunity to play more sports

0.214

0.429 0.643 0.286

I think being physically active helps me to be healthy

0.705 0.140 0.182 n/a

I would like to learn more about how food affects my health

0.616

0.499 0.274 0.218

I think my diet could be healthier 0.423 0.275 0.590 0.201

I am worried about the health of someone in my family

0.439 0.613 0.642 0.318

I think I am healthy 0.384 0.501 0.372 0.360

I think my family needs to learn what foods are healthy in the U.S.

0.299 0.197 0.197 0.664

I would like to exercise with only other boys/girls

0.361 0.668 0.620 0.681

I have tried to lose weight 0.435 0.435 0.069 0.627

I think my weight is good 0.213 0.798 0.767 0.010**

I think what I eat affects my health 0.538 0.283 0.514 0.495

I would like my family to learn how to cook American foods

0.594 0.557 0.571 0.128

Note. Survey questions listed in order of decreasing frequency interest/agreement Statistically significant differences are indicated *p<0.5, **p<0.10, ***p<0.01

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Dietary trends (pre- and post-arrival to U.S.), influences on food choices, nutrition

and health perceptions, and level of physical activity were also analyzed per geographic

region (see Table 5.18).

Table 5.18

ANOVA Results: Significant Differences by Geographic Region

Source of Variation

df

Mean Square

F

Sig

Pre-U.S. Fruit Consumption Within groups 58 2.725

3.416 0.023 Between groups 3 9.310

Pre-U.S. Vegetable Consumption

Within groups 57 1.809 6.975 0.000

Between groups 3 12.619

Pre-U.S. Milk Consumption Within groups 49 3.866

3.785 0.016 Between groups 3 14.631

Pre-U.S. Fruit Juice Consumption

Within groups 57 2.406 3.546 0.020

Between groups 3 8.533

Pre-U.S. Salty Snacks Within groups 57 3.133

2.728 0.052 Between groups 3 8.546

Pre-U.S. Physical Activity Within groups 58 3.245

2.824 0.047 Between groups 3 9.164

U.S. Meat Consumption Within groups 56 1.418

4.594 0.006 Between groups 3 6.513

U.S. Milk Consumption Within groups 53 2.132

3.002 0.039 Between groups 3 6.400

Taste- it has to taste good (food selection influences)

Within groups 57 0.419 4.203 0.009

Between groups 3 1.760

Religion (food selection influence)

Within groups 54 0.696 7.729 0.000

Between groups 3 5.379

Sports Preference for Physical Activity

Within groups 32 7.982 3.763 0.020

Between groups 3 30.040

Time in U.S. Within groups 52 0.202

3.343 0.026 Between groups 3 0.675

Time in Refugee Camp Within groups 12 31.186

4.423 0.036 Between groups 2 137.933

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Significant differences were observed between geographic regions regarding

preferences for physical activity with students from South East Asia preferring to go to

the “gym,” students from Africa and Central America preferring soccer, and students

from the Middle East reporting biking as their preferred method for physical activity.

Significant differences in time in the U.S. also were observed with students from

Central America residing in the U.S. the longest (e.g., 0.98 years for Central America vs.

0.55–0.59 years in other regions). In addition, dietary trends and influencing factors on

food choices varied per region. Students from Africa, the Middle East, and Southeast

Asia reported religion as “Very Important” as an influence on their food choices whereas

students from Central America were more likely to list religion as “Not Important.” Also,

students from Africa, the Middle East, and Southeast Asia reported taste as “Very

Important” as an influence on their food choices whereas students from Central America

were more likely to list religion as “Somewhat Important.” Lastly, diet trends varied

between groups with the greatest quantity of significant differences occurring in pre-

arrival diets and physical activity (e.g., the lowest amount of milk was consumed by

Southeast Asian and Central American students prior to arrival, the lowest amount of

vegetables were consumed by Central American students prior to arrival, and fruit and

fruit juice were the lowest for Southeast Asian and Central American students). Salty

snack consumption was the highest for students from the Middle East and lowest for

Southeast Asian students (mean consumption 5.4 vs. 3.27, 3.88, and 4.29). Upon arrival

to the U.S. milk consumption was the lowest in Central American students and highest

for African students (4.5 vs. 5, 5.78, and 5.95) and consumption of meat was the lowest

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for Central American and Southeast Asian students and the highest for Middle Eastern

students (4.56 and 4.58 vs. 6.11). 

In addition to the previous quantitative survey results, students were also provided

the opportunity to answer open-ended free response questions. Students were asked about

their preferences for exercise and sports with running, soccer, and basketball as the most

popular responses for both exercise as well as sport preferences. See Table 5.19.

Table 5.19

Open-ended Survey Question Data: Physical Activity

Survey Topic Themes

“I would like the opportunity to play more sports” (What sport? ________________)

Soccer, football, basketball, volleyball, running, tennis

I would like ____________ for exercise Running, soccer, basketball, gym/weights, swimming

Note. Themes listed by decreasing frequency in popularity and were listed by individual/different students ≥ n=2. Due to consistent similarity of activity preferences, PA themes not separated by language

Students were also asked about their diet within the open-ended free response

sections. Students most frequently reported vegetables, meat, fruit, and milk as healthy

foods and sweets, fast food, chips, oil/fat/greasy foods, and sodas as unhealthy foods (see

Table 5.20).

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Table 5.20

Open-ended Survey Question Data: Nutrition and Health

Survey Topic

Themes

English Spanish French Arabic Vietnamese Burmese

Healthy Foods (list)

Fruits (general fruits, apples, bananas) meat (chicken, meat), vegetables, eggs, juice, milk, “traditional: food, rice

vegetables, fruits, meat (fish, chicken, “meat”), salad, beans, eggs, rice, soup, juice

meat, vegetables, fruit, milk, rice

Meat (“meat”, chicken, fish), fruit, vegetables, legumes, milk

Meat (meat, fish, chicken), vegetable, milk

fruit (banana, orange, apple), vegetable

Unhealthy Foods (list)

sweets (“sugar, cake/cookies/ candy), soda, fast food, chips, milk

Fast food, soda (pizza, hamburger, hot dogs, fast food), sweets (cake, others), chips, oil/greasy/fried, salt, canned foods, beer, bread

chips, sweets,

sweets (dessert, candy, cookies, “sugar”), chips, soda, pork

soda, fast food, oil/fat

*Themes listed by decreasing frequency in popularity and were listed ≥ 2, if specific items listed more than twice per category they were listed in parenthesis following category

Students were also asked what foods were important for them to consume

regularly. These foods correlated with foods that were identified previously as “healthy”

foods and primarily focused on meats, vegetables, fruits, and milk (see Table 5.21).

Special foods to eat also included meat, rice, and injera (pancake-like bread common in

Ethiopian diets). Foods to avoid included pork and alcohol.

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Table 5.21

Open-ended Survey Question Data: Important Foods (Daily, Cultural)

Survey Topic

Themes

English Spanish French Arabic Vietnamese Burmese

Foods important to eat regularly

meat (chicken, “meat,” fish), fruit, vegetables, rice, milk, juice,

fruits, vegetables, meats (chicken, “meat”), salad, beans, rice, cereal, juice

Meat (variety-animal sources), fruit

fruits, vegetables, meat (meat, chicken), legume/beans, rice, milk/ yogurt

vegetables vegetables, beans

Special foods (to eat or avoid)

rice, meat (chicken, fish, goat), injera

vegetables (onions, cucumbers), chicken

pork, alcohol

pork, alcohol

meat

*Themes listed by decreasing frequency in popularity and were listed ≥ 2, if specific items listed more than twice per category they were listed in parenthesis following category

Lastly, students were given an opportunity within the open-ended free response

section of the survey to list any nutrition or health topics about which they would like to

receive more information or information. General nutrition (balanced diet), weight loss

and dieting information, information on American foods and how to select healthy foods,

portion sizes, and the specific effects of nutrition on health were the nutrition themes

identified (see Table 5.22). In addition, students were interested in information on how to

“stay healthy” as well as diet-related conditions such as diabetes.

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Table 5.22

Open-ended Question Survey Data: General Health/Nutrition Education Interest

(Request(s) for More Information)

Survey Topic Themes

Nutrition

general nutrition American foods weight loss healthy weight (what is “not too fat”) “unhealthy foods” “how do greasy foods effect my health” balanced diet basic nutrition and effects on health portion sizes “what should we eat”

General Health

diabetes “how to be healthy” “how to keep being healthy”

Discussion

The objective of this study was to examine nutrition and health knowledge,

changes (e.g., food choices, physical activity), perceptions, and interests of newcomer

youth. To the knowledge of the author the brief time in the U.S. (most less than one year)

and the diversity within this sample of newcomer adolescent participants are unique to

this study.

Students’ perceptions of the healthfulness of their diet and level of physical

activity pre- and post-arrival to the U.S. was widely variable. Upon more specific

questions regarding dietary trends pre- vs. post-arrival only one food category was found

to have declined (beans, legumes). Reported consumption of milk, meat, fruit juice, and

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soda consumption upon arrival to the U.S. were found to have been significantly

increased. No significant increases in salty snacks and sweets were identified. Few

studies have examined dietary trends pre- vs. post-arrival for comparison to identify

significant changes to the diet, and even less have quantified trends in consumption for

comparison. Studies which have examined pre-arrival diet compared to post-arrival diet

trends have identified similar results to this study. Dharod (2015) also found significant

increases in meat and dairy consumption upon arrival in the U.S. and a reduction in

consumption of legumes/beans in adult Montagnard women.36 Colby, Morrison, and

Haldeman (2009) identified increases in fruit juice consumption in Mexican immigrant

youth as well as an increase in snack foods and convenience foods.37

This study also identified significant increases in milk consumption. Milk

consumption has also been found to have increased in Asian youth over subsequent

generations and was less often a component of a traditional pre-arrival diet.7,23 Milk

consumption in Somali adolescent girls is reported to be higher at school than home, and

it is likely the access and promotion of milk with school lunch has promoted the

consistently reported increases in dairy in the U.S.38 This increase in milk consumption is

a positive change; for example, with Hispanic and Hmong children milk consumption has

been reported to be a significant predictor in decreasing ov/ob odds (vs. soda, which has

been significantly associated with ov/ob risk, and intake was reported to have increased

significantly in this study).16,23,39 These increases in milk, especially during adolescence,

suggest some positive and protective dietary changes in the U.S.; however, both soda and

fruit juice consumption were also found to have significantly increased upon arrival and

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are associated with obesity risk which is concerning due to the already elevated obesity

rates in this study which were higher than the national average (e.g., 17% vs. 14%,

respectively).40

In contrast to changes in dairy, meat, fruit juice, and soda, fruit and vegetable

consumption was not reported to have significantly changed. Other studies have found

fruit and vegetable consumption to have decreased in Hispanic youth over time;

decreases in vegetable consumption has been associated with insulin resistance in

Hispanic youth.23,41 Fruit and vegetable consumption has also been significantly

associated with less acculturation with Hispanic youth.21 Studies with Asian youth have

revealed varying trends. For example, in a study with Hmong youth, overall diet quality

has been reported to decrease over time as salt, fat, and overall calories increase;

however, in another study with generalized “Asian” youth, fruit and vegetable

consumption remained consistent through three generations.16,23 Participants in this study

did identify fruits, vegetables, and meats as important foods to consume daily and it is

possible that these foods did not change significantly upon arrival due to perceived daily

value and incorporation in the diet. It is also possible that these results (e.g., fruit,

vegetable, salty snacks, and sweets) are due to the early nature of arrival and limited

exposure to American culture (e.g., attending a specialized school limits opportunity to

come in contact with as many American peers); however, other significant changes were

reported to have occurred within this short timeframe (e.g., milk, soda, fruit juice).

Dietary acculturation was considered to be high within the brief time and

exposure in the U.S. with limited students reporting they had not tried any new foods or

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beverages (14.7% and 22.1%, respectively) and 33% percent of students reporting they

consume “only traditional meals at home.” Most students report good access to their

cultural foods as well as acceptance (taste) of their cultural foods here in the U.S.

Traditional meals at home are mostly prepared by mothers; food choices impacted by

both generations and eating together as a family was strongly valued across all students.

Dietary acculturation scores were associated increases in BMI in this study which has

been identified in other studies (e.g., dietary acculturation has also been identified as a

significant predictor of increases in BMI and poor diet quality with Hmong youth).16,20 It

is also important to note that dietary acculturation was measured by ranking incorporation

of new foods after arrival in addition to categorization of home meals (traditional vs.

American foods), where as in some studies it has been determined by level of

“association” with the host culture and/or the host culture’s foods.

Movement towards the “host diet” or “Westernized” diet is frequently reported

with newcomer youth; however, influencing factors on dietary choices and changes to the

diet (both positive and negative) are rarely assessed. Increase in affordability,

accessibility, and less time for food preparation have also been reported to be associated

with increased consumption of fast foods, convenience foods, and snack foods.8,10,29,37 In

contrast to these previously described study findings, results from this study found

dietary acculturation to be significantly associated with less perceived influence by

convenience or cost. This could also be due to the age of the participants in this study and

other studies mostly involving adult participants. In addition, TV advertising and peers

were the least likely to impact food choices. The level of exposure and/or quantity of

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screen time for students is unknown. It is possible that less exposure to American/English

television has resulted in the lack of influence. Food advertising may also vary by

language and if students are not as exposed to American/English television they may not

be as strongly influenced (e.g., Fleming et al. found Spanish television to have less food

advertising in comparison to American/English television).42 There was also a difference

in perceived influence of convenience by gender with female participants more likely to

report convenience to be of value; this may be due to their greater responsibility in

preparing food. Refugee camp experience was also significantly associated with a greater

range of perceived influences on food choices (e.g., family, culture, religion, etc.);

however, most of these perceptions were related to tradition and culture rather than taste,

cost, convenience, etc. More work is needed to understand the impact of refugee camp

experience on adolescents’ eating habits and weight gain in the U.S. (many in this study

spent the majority or all of their life in a refugee camp).

Students with higher BMIs were more likely to rank taste and less likely to rank

cost as an influencing factor. Dietary acculturation increases with BMI. It is possible that

those with less economic resources (currently and/or prior) may not have access to as

many new foods and that budget limitations reduce the willingness to incorporate new

foods which may not be favored. It is also possible that poor budgeting skills and

previous lack of access to socially valued foods have led to increased incorporation in the

U.S. despite budget restrictions and potentially poor economic resources with new

arrivals. In a study by Story and Harris, Vietnamese, Hmong, and Cambodian refugee

youth foods that were expensive but highly valued culturally (e.g., meat, fruits, soda)

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remained preferred and increased in consumption in the U.S.28 In a study by Franzen and

Castle with Hmong adults and adolescents it was reported, “you didn’t have that much

money back then but now it is like you are so much better off and you consume all this

stuff you don’t need . . .,” and participants reported consuming food in excess with

greater access and financial stability.10 In a paper by Rondinelli et al., lack of prior access

was found to increase consumption with refugees: “Many of them starved in the past so

when they do have food they will literally eat until they explode, figuratively of course.

I’ve seen it here.”9 It is possible that as newcomers have more resources to purchase food

they may be at more risk for gaining weight (can choose based on taste and not be as

concerned with cost).

With globalization of the food supply it is possible (or likely) that “dietary

acculturation” that exists under the assumption of moving towards the “host” country’s

diet may be oversimplified and that it is not necessarily a shift in increasing to “new

foods,” but rather increased incorporation due to changes to this improved access and

affordability. It may be more accurate to report “diet changes” in place of “dietary

acculturation.” For example, studies with Mexican groups have found access to a variety

of snack and convenience foods as well as soda prior to arriving to the U.S., suggesting

that moving to the U.S. does not introduce these foods but rather makes them more

accessible.37 Moreover, many studies lack assessment of pre-arrival diet which further

limits assessment of change.

In addition to the dietary changes, trends, and influencing factors, physical

activity was also examined in this study, as activity level is strongly associated with long-

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term health and chronic disease prevention. This study found reported physical activity to

have decreased upon arrival to the U.S. with high interest (>80%) in increasing physical

activity (especially sports). Specific preferences regarding activities were also identified

with running, soccer, and basketball as top preferences. Physical activity is more strongly

associated with perceived influence on health outcomes than diet (83.1% vs. 41.5%,

respectively). Students demonstrated basic knowledge with regard to nutrition (e.g.,

fruits, vegetables, and milk were listed as healthy foods and salt, sugar, and fat as

unhealthy). Studies examining health literacy with newcomer youth is limited but has

been incorporated in some nutrition studies. In a study with Hmong young adults and

youth, fruit and vegetable consumption and physical activity are associated with health. A

study with Somali female adolescents demonstrated an understanding of dairy and

calcium for bone health, and a study with African youth demonstrated an understanding

of the adverse effects of low physical activity, sugar, and oil on health.8,19,29,38 Students

had a very basic sense of nutrition; however, it is concerning that they did not perceive

their diet as valuable as physical activity in supporting health. Despite these concerning

perceptions, in the open-ended section students most frequently reported interest in

obtaining more nutrition information and how to be/stay healthy despite the limited

association of diet with health.

Physical activity was most strongly associated with maintaining and supporting

health, and students were very interested in having more opportunities to be active. Many

studies have found decreases in physical activity upon arrival for a variety of reasons—

less incorporation in daily living activities, less safe space, and less access to organized

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sports.8,19,23,27,29,30,37 Some studies have also identified higher cultural barriers by gender;

for example, Hispanic and African girls (e.g., Sudanese mother “not married, may not go

out alone”) may be less likely to be allowed out on their own which may serve as a

barrier to participate in recreational physical activity.8,29 Additionally, a study with

Hmong young adults and adolescents reported concerns with young females having too

much physical exertion or activity and the negative effect on fertility.29 The potential for

less access to physical activity for female adolescents is especially concerning in light of

the higher level of ov/ob in female vs. male participants in this study (e.g., 37% vs. 25%

overweight, and 23% vs. 8% obese, respectively).

The overall high level of overweight and obesity in this sample is concerning. A

study with refugee pediatric patients found ov/ob rates to double over a span of three

years and a study with Hmong youth found increases in BMI to be associated with high

blood pressure.18,43 The high rates of obesity may also correspond with the reported body

dissatisfaction and weight-related concerns. Only 36.1% of students report satisfaction

with their weight (e.g., “I think my weight is good”), 46.8% have tried to lose weight, and

45.8% have had someone (usually a parent) discuss their weight with them. Dieting

information and “healthy weight” were also frequently listed as a nutrition topic about

which students wanted more information. BMI was also significantly associated with

perception of weight, as students with a normal BMI were most likely to agree with the

statement, “I think my weight is good.”

Body dissatisfaction and unhealthy and extreme dieting behaviors have been

identified with diverse, newcomer youth. Dieting behaviors have also been associated

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with higher BMIs long-term.44 To further complicate the picture, differences in weight

have been identified between generations in other studies in both African and Asian

families with parents concerned about their children’s weight gain or cultural favoritism

towards excess weight and gaining weight indicating social and economic status, health,

and positive parenting and provision for the family.10,30 Youth have been reported to be

torn between their parents’ desire for them to gain weight and to fit in with Westernized

cultures that favor “thinness.”10,30 It is also unknown if body dissatisfaction reported here

and elsewhere is attributed directly to Westernized culture and/or media influence. In a

study by Lopez et al. (2013), media was not found to influence perception of appearance

or disordered eating in Hispanic youth.45 Studies with a variety of diverse youth

participants (Hmong, Hispanic, Somali, and other African groups) have found extreme

weight management and dieting behaviors, poor body image, and high body

dissatisfaction.25,27,30,44,46 Studies with influence on body satisfaction, weight, and dieting

are limited with diverse and newcomer youth despite documented risks of poor body

image. Dieting behaviors and future research in this area is warranted, particularly in

light of long-term repercussions of dieting behaviors on increased future BMI and

therefore chronic disease risk.

Some students may be at greater risk for obesity and long-term chronic diseases.

For example, students from Central America and the Middle East had the highest rates of

ov/ob. Students from Central America had the highest rates of ov/ob and had resided in

the U.S. significantly longer than students from other regions, suggesting that length of

time the U.S. may be associated with increased risk of ov/ob as has been found in other

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studies.18,43,47 Students from the Middle East had the highest dietary acculturation scores.

Furthermore, other significant differences between geographic regions regarding dietary

trends pre- and post-arrival to the U.S. reported observing influencing factors on food

choices as well as physical activity levels and preference.

Students in different geographic regions significantly differed in their

consumption of major food groups by geographic region (e.g., fruit, vegetables, milk,

fruit juice, and salty snacks pre-arrival) as well as post-arrival (e.g., meat, milk). Students

also varied in their preferences for physical activity (e.g., African and Central American

students prefer soccer, students from the Middle East prefer biking, and Southeast Asian

students prefer “going to the gym” for physical activity). Reported influence on food

choices also varied, with Central American students the least influenced by taste and/or

religion. These findings highlight distinct needs and preferences of students from varying

geographic regions. Moreover, although all students were “newcomers,” they arrived

from 35 different nations, each bringing individual backgrounds, experiences,

preferences, and needs which were observed by these significant differences per region.

These regional differences support the need to evaluate and focus on the unique and

distinct cultural trends, needs, and perceptions of individual groups to design tailored,

targeted future interventions and resource development.

There are limitations to this study. The diversity of the sample made it difficult to

group participants during analysis, and groups were derived by geographic area rather

than nationality or ethnicity. This may have impacted the results, particularly in bivariate

analysis. Differences in language between the translations of the survey may also have

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impacted the reliability of the data analysis and results. Although a unique factor in this

study, the timeline and limited exposure and experience in the U.S. may have muted the

changes reported and experienced by the students. It is possible that if the study had been

conducted after more time and/or exposure to American culture greater changes and/or

perceptions and influencing factors may have been reported. However, this limited

exposure to American culture was also a unique factor of this study. Lastly, despite these

proposed limitations this study did find many consistent trends across a very diverse

group of newcomers which suggests some consistency in experience for newly-arrived

youth (e.g., desire for more PA, high levels of dietary acculturation, increase in soda, fruit

juice, milk, meat, body dissatisfaction).

Many questions remain and should be the focus of future studies. A unique

component of this study was the assessment of influencing factors on dietary choices;

however, much more needs to be examined to understand the driving forces in dietary

change. More research should be conducted to evaluate exactly why/how food choices

change and how this varies or is consistent between different major incoming groups. In

order to address unhealthy changes to diet, future research should better examine dietary

trends as well as social and economic changes pre- vs. post-arrival. In addition to dietary

changes, physical activity is also an area to be addressed in future studies. Gender

differences in access as well as interests should also be further evaluated as well as

identifying preferences and cultural appropriate physical activity opportunities between

genders and groups. In light of the ov/ob rates, diet trends, and weight concerns,

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improving PA may offer many positive promises in maintaining a healthy weight and

reducing long term chronic disease risk, poor body image, and weight dissatisfaction.

This study identified high levels of overweight and obesity population, significant

(negative and positive) dietary changes, strong interest and need to improve physical

activity access, and poor body image in a diverse group of newcomer youth. This study

quantified diet and PA levels pre- and post-arrival, traditional food access, and dietary

acculturation, perceptions that guide food choices and health literacy. Differences per

region were also identified in pre- and post-arrival dietary trends, PA preferences, and

influencing factors on food choices. Despite many new and unique findings, more work

is needed to better understand newcomer youth to reduce the many risks identified in

these populations (e.g., ov/ob, limited PA, preferences and needs within cultural groups,

poor body image, poor diet) to support their long-term health and reduce the risk of

chronic disease and disparities with these populations. Lastly, interventions focusing on

newcomer youth are limited to unknown for many cultural groups, and due to their risk

level for chronic disease (e.g., limited PA, poor diet, ov/ob trends), future research should

invest in developing and evaluating interventions targeted at newcomer youth.

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References

1. Monger, R., & Yankay, J. (2014, May). Annual Flow Report 2013: US Lawful

Permanent Residents. Retrieved from http://www.dhs.gov/publication/us-lawful-permanent-residents-2013

2. Martin, D. C., & Yankay, J. E. (2013). Annual Flow Report 2013: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ois_rfa_fr_ 2013.pdf

3. US Citizenship and Immigration Services-RAIO-Asylum Division. (2009, March 6). Asylum Officer Basic Training Course. Eligibility Part I. Definitions; Past Persecution. Retrieved from http://www.uscis.gov/sites/default/files/USCIS/ Humanitarian/Refugees%20%26%20Asylum/Asylum/AOBTC%20Lesson%20Plans/Definition-Refugee-Persecution-Eligibiity-31aug10.pdf

4. Colby, S. L., & Ortman, J. M. (2015). Projections of the size and composition of the U.S. population: 2014 to 2060. Population Estimates and Projections. Retrieved from http://www.census.gov/content/dam/Census/library/publications/2015/demo/ p25-1143.pdf

5. Pereira, C., Larder, N., & Somerset, S. (2010). Food acquisition habits in a group of African refugees recently settled in Australia. Health & Place, 16(5), 934–941. doi:10.1016/j.healthplace.2010.05.007

6. Adekeye, O., Kimbrough, J., Obafemi, B., & Stack, R. (2014). Health literacy from the perspective of African immigrant youth and elderly: A PhotoVoice project. Journal of the Poor and Underserved, 25(4), 1730–1747. doi:10.1353/hpu.2014.0183

7. Vue, W., Wolff, C., & Goto, K. (2011). Hmong food helps us remember who we are: Perspectives of food culture and health among Hmong women with young children. Journal of Nutrition Education and Behavior, 43(3), 199–204. doi:10.1016/j.jneb.2009.10.011

8. Wilson, A., & Renhazo, A. (2014). Intergenerational differences in acculturation experiences, food beliefs, and perceived health risks among refugees from the Horn of Africa in Melbourne, Australia. Public Health Nutrition, 18(1), 176–188. doi:10.1017/S1368980013003467

131

 

9. Rondinelli, A. J., Morris M. D., Rodwell T. C., Moser K.S., Paida P., Popper S.T., & Brouwer K. C. (2011). Under- and over-nutrition among refugees in San Diego County, California. Journal of Immigrant and Minority Health, 13(1), 161–168. doi:10.1007/s10903-010-9353-5

10. Franzen, L., & Smith, C. (2009). Acculturation and environmental change impacts dietary habits among adult Hmong. Appetite, 52(1), 173–183. doi:10.1016/j.appet.2008.09.012

11. Garnweidner, L. M., Terragni, L., Pettersen, K. S., & Mosdol, A. (2012). Perceptions of the host country’s food culture among female immigrants from Africa and Asia: Aspects relevant for cultural sensitivity in nutrition communication. Journal of Nutrition Education and Behavior, 44(4), 335–342. doi:10.1016/j.jneb.2011.08.005

12. Peterman, J. N., Silka, L., Bermudez, O. I., Wilde, P. E., & Rogers, B. L. (2011). Acculturation, education, nutrition education, and household composition are related to dietary practices among Cambodian refugee women in Lowell, MA. Journal of the American Dietetic Association, 111(9), 1369–1374. doi:10.1016/j.jada.2011.06.005

13. Tiedje, K., Wieland, M. L., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2014). A focus group study of healthy eating knowledge, practices, and barriers among adult and adolescent immigrants and refugees in the United States. International Journal of Behavioral Nutrition and Physical Activity, 11, 63. doi:10.1186/1479-5868-11-63

14. Anderson, L. C., Mah, C. L., & Sellen, D. W. (2015). Eating well with Canada’s food guide? Authoritative knowledge about food and health among newcomer mothers. Appetite, 91, 357–365. doi:10.1016/j.appet.2015.04.063

15. Mannion, C. A., Raffin-Bouchal, S., & Henshaw, C. J. (2014). Navigating a strange and complex environment: Experiences of Sudanese refugee women using a new nutrition resource. International Journal of Women’s Health, 16(6), 411–422. doi:10.2147/IJWH.S56256

16. Mulasi-Pokhriyal, U., Smith, C., & Franzen-Castle, L. (2012). Investigating dietary acculturation and intake among US-born and Thailand/Laos-born Hmong-American children aged 9–18 years. Public Health Nutrition, 15(1), 176–185. doi:10.1017/S1368980011001649

17. Hrboticky, N., & Krondl, M. (1984). Acculturation to Canadian foods by Chinese immigrant boys: Changes in the perceived flavor, health value and prestige of foods. Appetite, 5(2), 117–126. doi:10.1016/S0195-6663(84)80031-8

132

 

18. Smith, C., & Franzen-Castle, L. (2012). Dietary acculturation and body composition predict American Hmong children’s blood pressure. American Journal of Human Biology, 24(5), 666–674. doi:10.1002/ajhb.22295

19. Wieland, M. L., Tiedje, K., Meiers, S. J., Mohamed, A. A., Formea, C. M., Ridgeway, J. L., . . . Sia, I. G. (2015). Perspectives on physical activity among immigrants and refugees to a small urban community in Minnesota. Journal of Immigrant and Minority Health, 17, 263–275. doi:10.1007/s10903-013-9917-2

20. Franzen-Castle, L., & Smith, C. (2014). Environmental, personal, and behavioral influences on BMI and acculturation of second generation Hmong children. Maternal and Child Health Journal, 18(1), 73–89. doi:10.1007/s10995-013-1235-8

21. Diaz, H., Marshak, H. H., Montgomery, S., Rea, B., & Backman D. (2009). Acculturation and gender: Influence on healthy dietary outcomes for Latino adolescents in California. Journal of Nutrition Education and Behavior, 41(5), 319–326. doi:10.1016/j.jneb.2009.01.003

22. Liu, J. H., Chu, Y. H., Frongillo, E. A., & Probst, J. C. (2012). Generation and acculturation status are associated with dietary intake and body weight in Mexican American adolescents. Journal of Nutrition, 142(2), 298–305. doi:10.3945/jn.111.145516

23. Allen, M. L., Elliott, M. N., Morales, L. S., Diamant, A. L., Hambarsoomian, K., & Schuster, M. A. (2007). Adolescent participation in preventive health behaviors, physical activity, and nutrition: Differences across immigrant generations for Asians and Latinos compared with Whites. American Journal of Public Health, 97(2), 337–343.

24. Morris, M. D., Popper, S. T., Rodwell, T. C., Brodine, S. K., & Brouwer, K. C. (2009). Healthcare barriers of refugees post-resettlement. Journal of Community Health, 34(6), 529–538. doi:10.1007/s10900-009-9175-3

25. Arcan, C., Larson, N., Bauer, K., Berge, J., Story, M., & Neumark-Sztainer, D. (2014). Dietary and weight-related behaviors and body mass index among Hispanic, Hmong, Somali, and white adolescents. Journal of the Academy of Nutrition and Dietetics, 114(3), 375–383. doi:10.1016/j.jand.2013.11.019

26. Batis, C., Hernandez-Barrera, L., Barquera, S., Rivera, J. A., & Popkin, B. M. (2011). Food acculturation drives dietary differences among Mexicans, Mexican Americans, and Non-Hispanic Whites. Journal of Nutrition, 141(10), 1898–1906. doi:10.3945/jn.111.141473

133

 

27. Stang, J., Kong, A., Story, M., Eisenberg, M. E., & Neumark-Sztainer, D. (2007). Food and weight-related patterns and behaviors of Hmong adolescents. Journal of the American Dietetic Association, 107(6), 936–941.

28. Story, M., & Harris, L. J. (1989). Food habits and dietary change of Southeast Asian refugee families living in the United States. Journal of the American Dietetic Association, 89(6), 800–803.

29. Kim, L. P., Harrison, G. G., Kagawa-Singer, M. (2007). Perceptions of diet and physical activity among California Hmong adults and youths. Preventing Chronic Disease, 4(4), A93.

30. Renzaho, A. M., McCabe, M., & Swinburn, B. (2012). Intergenerational differences in food, physical activity, and body size perceptions among African migrants. Qualitative Health Research, 22(6), 740–754. doi:10.1177/1049732311425051

31. Martin, D. C., & Yankay, J. E. (2012). Annual Flow Report 2012: Refugees and Asylees. U.S. Department of Homeland Security Office of Immigration Statistics. Retrieved from https://www.dhs.gov/sites/default/files/publications/ ois_rfa_fr_2012.pdf

32. American Immigration Council. (2013). New Americans in North Carolina: The political and economic power of immigrants, Latinos, and Asians in the Tar Heel State. Retrieved from http://www.immigrationpolicy.org/sites/default/files/docs/ new_americans_in_north_carolina_2015.pdf

33. Refugee Council USA. (n.d.). The US Resettlement Program in North Carolina. Retrieved from http://www.rcusa.org/uploads/pdfs/WRD-2014/North-Carolina.pdf

34. Centers for Disease Control and Prevention. (n.d.). Children’s BMI calculator for schools. Atlanta, GA: Author. Retrieved from http://nccd.cdc.gov/dnpabmi/ calculator.aspx

35. Elo, S., & Kyngäs, H. (2008). The qualitative content analysis process. Journal of Advanced Nursing, 62(1), 107–115. doi:10.1111/j.1365-2648.2007.04569.x

36. Dharod, J. M. (2015). What changes upon resettlement: Understanding difference in pre- and post-resettlement dietary habits among South-Asian refugees. Ecology of Food and Nutrition, 54(3), 209–223. doi:10.1080/03670244.2014.964800

37. Colby, S., Morrison, S., & Haldeman, L. (2009). What changes when we move? A transnational exploration of dietary acculturation. Ecology of Food and Nutrition, 48, 327–343.

134

 

38. Benbenek, M. M., & Garwick, A. W. (2012). Enablers and barriers to dietary practices contributing to bone health among early adolescent Somali girls living in Minnesota. Journal for Specialists in Pediatric Nursing, 17(3), 205–214. doi:10.1111/j.1744-6155.2012.00334.x

39. Beck, A. L., Tschann, J., Butte, N. F., Penilla, C., & Greenspan, L. C. (2014). Association of beverage consumption with obesity in Mexican American children. Public Health Nutrition, 17(2), 338–344. doi:10.1017/S1368980012005514

40. Centers for Disease Control and Prevention. (n.d.). The obesity epidemic and United States students. Atlanta, GA: Author. Retrieved from http://www.cdc.gov/ healthyyouth/data/yrbs/pdf/us_obesity_combo.pdf

41. Cook, L. T., O’Reilly, G. A., Goran, M. I., Weigensberg, M. J., Spruijt-Metz, D., & Davis, J. N. (2014). Vegetable consumption is linked to decreased visceral and liver fat and improved insulin resistance in overweight Latino youth. Journal of the Academy of Nutrition and Dietetics, 114(11), 1776–1783. doi:10.1016/j.jand.2014.01.017

42. Fleming-Milici, F., Harris, J. L., Sarda, V., & Schwartz, M. B. (2013). Amount of Hispanic youth exposure to food and beverage advertising on Spanish- and English-language television. JAMA Pediatrics, 167(8), 723–730. doi:10.1001/jamapediatrics.2013.137

43. Heney, J., Dimock, C., Friedman, J., & Lewis, C. (2015). Pediatric refugees in Rhode Island: Increases in BMI percentile, overweight, and obesity following resettlement. Rhode Island Medical Journal, 98(1), 43–47.

44. Neumark-Sztainer, D., Wall, M, Haines, J, Story, M, & Eisenberg, M. E. (2007). Why does dieting predict weight gain in adolescents? Findings from project EAT-II: A 5-year longitudinal study. Journal of the American Dietetic Association, 107(3), 448–455.

45. Lopez, V., Corona, R., & Halfond, R. (2013). Effects of gender, media influences, and traditional gender role orientation on disordered eating and appearance concerns among Latino adolescents. Journal of Adolescence, 36(4), 727–736. doi:10.1016/j.adolescence.2013.05.005

46. Neumark-Sztainer, D., Croll, J., Story, M., Hannan, P. J., French, S. A., & Perry, C. (2002). Ethnic/racial differences in weight-related concerns and behaviors among adolescent girls and boys: Findings from Project EAT. Journal of Psychosomatic Research, 53(5), 963–974. doi:10.1016/S0022-3999(02)00486-5

47. Himmelgreen, D. A., Pérez-Escamilla, R., Martinez, D., Bretnall, A., Eells, B., Peng, Y., & Bermúdez, A. (2004). The longer you stay, the bigger you get: Length of time

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and language use in the U.S. are associated with obesity in Puerto Rican women. American Journal of Physical Anthropology, 125(1), 90–96.

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CHAPTER VI

EPILOGUE

This work provided a unique opportunity to interact with a diverse group of

newcomer families and adolescents. It was an incredible learning experience and it

solidified my interest and passion to work with international populations.

One of the most emotional components of this work was the “behind the scenes”

effort to be culturally competent regarding the individual conditions from which the

families and adolescents were arriving. As I began to collect data and see from where the

students and families were arriving, I would study the current political and social

conditions that pushed so many individuals to flee their homes or to start over in the U.S.

As I read about the violence driving Latino immigrants out of Honduras and El Salvador

and the continuing conflicts all over Africa and the Middle East my heart was heavy, and

then I would arrive at the school and interact with resilient, smiling, laughing energetic

adolescents. One in particular, a smaller, male student from the Sudan with the most

beautiful smile and name that I will always remember will stay with me forever. I

remember asking one of my Arabic interpreters to help me say a few words in Arabic to

him. As I stumbled over what I am sure was horrible Arabic, I still remember his

beautiful smile lighting up his face as I undoubtedly butchered his language. There were

so many students in this study whom I will never forget.

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Many of my refugee adolescent participants had spent their entire lives in a

refugee camp. While this finding was not surprising to me, as I was well aware of how

long many groups had been experiencing conflict, it was still very difficult to consider,

especially as I now know their faces and their stories. I cannot begin to imagine what

many have lived through and yet here they are in the U.S. attending the school. They are

smiling and laughing. They are eating pizza and trying Starbucks for the first time. They

are hanging out with their friends and they will have a chance at a new life. But what will

that new life be? What opportunities will be available to them? Especially the older

students—as a former high school teacher, these are the questions I find myself

pondering.

If I am able to accomplish anything, it will be to strive to not only “assess” these

groups but to work to alongside them to utilize their resilience, resourcefulness, strength,

and capacity to move forward in their lives and partner to develop programs and

interventions that work with them earlier upon arrival with the hopes to reduce their risks,

their vulnerabilities. Future work must be community based, participatory, and build

upon the many inherent strengths of newcomer groups.

Lastly, although this was an overall positive experience it was most certainly not

an easy experience. Community-based research is complicated. It is even more

complicated when it involves six languages and requires multiple interpreters and

translators to accomplish data collection. There were large cultural and communication

barriers with the school staff who served as the initial translators and interpreters to arrive

on time and to the right location for data collection. This was especially difficult as all

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data were collected during very narrow time constraints (e.g., only Art and P.E. classes,

as students could not miss other classes). Each of the school’s staff worked different

schedules—not all were fulltime staff, and the part-time staff did not have as much time

to help with the data collection. There were days where I couldn’t locate an interpreter,

even if one was scheduled, and I would have students waiting on the interpreter to

complete the assent process per the study protocol. At first I relied completely on the

school’s staff for translation and interpretation, but as I needed to give more surveys and

their interpreters/translators had other obligations I began to recruit and train additional

individuals. I think at the end of data collection I went from five initial interpreters/

translators to a total of 20 in addition to several research assistants. The constant

scheduling and communicating with so many moving parts for data collection due to the

language barriers was exhausting.

In addition, the narrow time available for data collection was at times very

difficult, especially with the middle school students; however, by collecting data during

school hours I was assured access to the students on a daily basis. The middle school

students needed a lot more help and were much slower taking the surveys, which often

required two sessions and then also locating them a second day to finish. Many middle

school surveys were left incomplete as the students could not be found or an interpreter

could not be present to finish the surveys. Sometimes the students who started a survey

and needed to finish were located and the interpreter then couldn’t be located or the

interpreter was on time and at the right location but the student didn’t show up or was not

at school that day; the interpreter arrived with nothing to do, which was not enjoyable for

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them (especially as all were volunteers and not paid). It seems now looking back to be a

miracle how many total and complete surveys were given. In addition to the previously

described complexities, enrollment at the school is ongoing year round and new

recruitment packets were sent home and the potential participant pool was always

shifting.

All frustrations aside, the schools staff, especially the principal, made this study

possible. The principal and the school’s flexibility in allowing me to return multiple days

to reach more students was vital to the success of this study. The principal’s support and

encouragement to keep locating students and giving surveys until the day before

standardized testing started in June (literally right before school let out for the summer)

was an enormous gift. It was truly a blessing to work with so many wonderful school

staff members. Each one worked hard to help me recruit participants and find students. I

am incredibly grateful for the school’s staff. This reinforces the value of identifying,

building, and maintaining relationships with strong community organizations to support

research and programming/interventions. I will be forever grateful to the school’s staff

and will never forget the many amazing individuals from all over the world with whom I

had the privilege to work on this project. I look forward to enriching my life in the future

by continuing to partner with and conduct research with diverse populations, especially

immigrants and refugees.

Future Work

As the U.S. becomes more and more diverse it is vital to national, state, and local

public health goals to better understand the pre- and post-arrival experiences, knowledge,

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concerns, interests, and needs of newcomer groups. Due to the evidence of vulnerability

and nutrition and health-related disparities and limited data regarding immigrant and

refugees (newcomer groups), it is warranted to continue research with these groups. Due

to the lifestyle and chronic disease-related risk factors for newcomer caregivers and

adolescents, earlier intervention (within the first year in the U.S.) should be explored to

reduce long-term weight gain, negative dietary acculturation, and reductions in physical

activity. The long-term efficacy of such interventions (e.g., longitudinal studies) will

likely be complicated but key in supporting and improving nutrition and health promotion

efforts and reducing health disparities.

Future work (particularly assessment studies) should continue incorporating

comparative studies with multiple groups; however, interventions and/or resource

development should focus on individual groups to ensure proper targeting and cultural

appropriateness. Dietary “acculturation” changes as well as physical activity changes

should be further explored. Many barriers to physical activity in particular have been

reported; however, little work has sought to improve physical activity access and

participation, particularly in groups with high language, gender, and cultural barriers.

Future work should continue to examine barriers as well as approaches and outreach that

can be successful in increasing physical activity opportunities for immigrant and refugee

groups, especially in light of their chronic disease risk. Barriers for females for physical

activity, their increased concern for weight gain and demonstrated higher levels of ov/ob

suggest focusing on gender/female-specific and culturally appropriate physical activities.

Furthermore, development of a validated tool to assess the level of dietary and physical

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activity changes and/or health literacy to better standardize and measure incoming groups

would also be of value. In addition, research should continue to examine concerns

relating to body image, especially due to the future risk of poor dietary behaviors and

trends for increased BMI and related health concerns as well as the social element with

weight, particularly in adolescents.

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APPENDIX A

LET’S TALK ABOUT FOOD PARENT GROUP GUIDE

1. What foods do you eat regularly?

2. Are there foods you cannot find you would like to eat?

3. How do you think your diet compares to before you came to the U.S.?

4. Do you have any concerns about what your family or children are eating now that you are in the United States?

5. Would you be interested in learning what foods are important for your child’s growth and health?

6. Would you be interested in tasting new foods and trying new recipes with healthy, affordable fresh American foods?

7. Would you be interested in learning about diets that help reduce the risk of hypertension/high blood pressure, diabetes, weight gain, or heart disease?

8. American foods have labels that explain what are in the foods. Would you be interested in learning how these labels can help you make healthy choices?

9. Would you be interested in having someone shop with you to help explain healthy options or American products or how to navigate American grocery stores?

10. Would you be interested in attending nutrition education in your community another day? What topics about nutrition or related health would you be interested in learning about?

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APPENDIX B

NUTRITION GUIDELINES: PROMOTING YOUR FAMILY’S HEALTH AND REDUCING DISEASE RISK

“5 A Day” Eat 5 Fruits and Vegetables Daily

Compare Labels

↑Fiber, Calcium, Iron,

Vitamin A, C, D ↓Sodium, Saturated Fat,

Sugar

Re- Think Your Drink

Sugary Drinks = ↑weight

gain, dental problems, risky for diabetics

Choose Whole Grains

Foods for Bone Health

Childhood and adolescence is a very important time for

bone growth!

Be Active as a Family!

Limit these “Sometimes” foods for treats or special occasions

Physical Activity and Healthy Diet:

↑ Energy ↑ Immunity

↑Bone health

↓ Risk Diabetes ↓Risk of High Blood

Pressure ↓ Risk of Heart Disease,

Stroke

Iron Containing Foods

Important for Energy,

Growth, Brain Development

Photo Credits: 1) nkfstayinghealthy.wordpress.com, 2) http://betterthancookingmama.tumblr.com/ post/17704313510/whats-so-shocking-about-this-picture-take-a, 3) http://www.dietsinreview.com/ diet_column/03/the-conspiracy-to-make-us-all-junk-food-junkies-breaking-down-new-york-times-addictive-junk-food-story/, 4) www.modernghana.com, 5) www.n4foodandhealth.com, 6) blogfoodforthought.com, 7) www.nutritionremarks.com, 8) www.nymetroparents.com

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APPENDIX C

STUDY FLYER

Let’s Talk About Food!

Project Title: Let’s Talk About Food! Principal Investigator: Lauren Sastre MS Faculty Advisor: Lauren Haldeman PhD What is this all about? Let’s Talk About Food is a study to learn about the food choices and changes new youth and families experience upon arrival in the United States. You are being asked to participate because your family is new to the United States. Your participation in this research project is voluntary. If you choose to participate you can provide feedback about what nutrition and health related topics you believe are important today. Your nutrition and health interests and concerns may help guide the development of resources to support other new families who come the U.S. and North Carolina in the future. How will this negatively affect me or my family? There are no foreseeable risks involved with this study. What will I or my family get out of this research project? You will not likely directly benefit from this study. The information that is collected may be used to develop resources and guide nutrition and health promotion and education to support the nutrition and overall health and well-being of other families in the future. Will I get paid for participating? You will not be paid. What about my confidentiality? No identifying information such as your name or where you live will be asked of you. You will only be asked questions about your interest or concern regarding nutrition or food issues and general health topics.

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What if I do not want to be in this research study? You do not have to be part of this project. You do not have to respond to any questions or topics discussed today. This project is voluntary and it is up to you to participate. If you agree to participate, at any time in this project you may stop participating without penalty. If you choose not to participate in this study or to withdraw this will not affect your relationship with or services received from the Doris Henderson Newcomer’s School. What if I have questions? You can ask the research assistant Lauren Sastre 336-202-0599 or the principle investigator Lauren Haldeman PhD 336-256-0311 anything about the study. If you have concerns about how you have been treated in this study call the Office of Research Integrity Director at 1-855-251-2351.

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APPENDIX D

CAREGIVER CONSENT SCRIPT

Let’s Talk Food

Adult Discussion Group Consent Script

Introduction Script (to be translated to primary language by community liaison during the community education day at the school). The flyer (translated into primary language as well) will be circulated during the introduction. This flyer is attached in a separate file. “Introduction: “Good Morning/Afternoon, thank you for having me here today. I am here to talk about food, nutrition and health. I am a student at a local university in the Department of Nutrition. I have passed around a flyer that describes my project. I have some questions about food and nutrition. If you are would like to participate by raising your hand or discussing any of the points today I will write down your interests or concerns. I will not ask for your name, where you live or any other personal information. I will use the nutrition and health topics you are interested, as well as feedback on foods you like to eat to help me make resources to support good nutrition and health of families with children here at the school in the future. You do not have to share any information. If you choose to I will write down the things you are interested in or concerned about. When I have finished asking a few questions I will be happy to discuss any nutrition or general health topics you are interested in or have concerns about and I will not collect any information then.”

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APPENDIX E

ADOLESCENT GROUP DISCUSSION GUIDE

Let’s Talk About Food Student Focus Group Guide:

I. Opening/Icebreaker Questions

a) Let’s start of by introducing ourselves by name, where you are from, and something about you, what you like to do or something that is important to you.

b) Now let’s go around and share one of your favorite foods. c) Great, thank you, today I would like to talk to you about health and healthy

eating. I have some questions for us to discuss as a group about health as well as healthy eating.

II. Health/Eating Questions 1. What do you think it means to be “healthy”? Do you think you are healthy? Why or

why not?

2. Are there things you can do to be healthy? Are there things that make you less healthy?

3. What is a healthy diet? What foods would be in a healthy diet? What makes them healthy or unhealthy?

4. Do you think your diet is healthy? Why or why not?

5. What do you like to eat? How do you choose what to eat?

6. Are there any foods that have special meaning or are important in your family or culture? What are they? Why are they important?

7. Are there any nutrition or health topics you would like to learn more about? What are they?

8. What have been some of the biggest changes/differences to your everyday eating now that you are in the U.S.? Why do you think your eating has changed?

9. What have been some of the biggest changes/differences in how active you are? Why do you think your activity has changed?

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10. What new foods have you tried? (Follow-up questions: a) How do you decide what new foods to try? b) Would you like to try more American foods? why/why not? c) Would you like to learn which American foods are healthy?

11. Do you think how active you are or exercise affects your health? Why or why not? What kind of exercise would you be interested in?

12. Is there anything related to food and nutrition that I did not talk about that you would like to learn more about or talk about?

13. Is there anything related to your health that I did not talk about that you would like to learn more about or talk about?

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APPENDIX F

ADOLESCENT STUDY FLYER

Let’s Talk About Food!

  Project Title: Let’s Talk About Food! Principal Investigator: Lauren Sastre MS Faculty Advisor: Lauren Haldeman PhD What is this all about? Let’s Talk About Food is a study to learn about the diet preferences, choices and changes youth ages 12-17 and families experience when they come to the United States. Your child is being asked to participate in this study because they are new to the United States. This research project involves your child taking a survey about eating and food that will likely take about an hour and a half. Your child may also participate in a small group discussion about eating and general health interests and knowledge. They will also have their height and weight taken. Your child’s participation in this research project is voluntary. The survey and small group discussions will take place at school and each will last about an hour and a half for each. How will this negatively affect my child? There are no foreseeable risks involved with this study. Your child does not have to respond to any question they are not comfortable answering in either the survey or the focus group and they may choose to withdraw at any time. What will my child get out of this research project? Your child will not likely directly benefit from this study. Will I get paid for participating? Your child will not be paid. What about my confidentiality? We will do everything possible to make sure that your child’s information is kept confidential. Your child’s information will only be accessible by the research assistant and principle investigator of this study. The survey data will be kept in a locked cabinet file and any reports or data from this study will not include identifying information of your child such as their name or where they or you live. What if I do not want to be in this research study? Your child does not have to be part of this project. This project is voluntary and it is up to you and your child to participate in this research project. If you agree to participate at any time in this project you may

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stop participating without penalty. Choosing not to participate in this study or to withdraw at any time will not affect the services provided or your relationship with Doris Henderson Newcomer’s School. What if I have questions? You can ask the principal investigator Lauren Sastre 336-202-0599 or the faculty advisor Lauren Haldeman PhD 336-256-0311 anything about the study. If you have concerns about how you have been treated in this study call the Office of Research Integrity Director at 1-855-251-2351.

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APPENDIX G

PARENT CONSENT FORM

UNIVERSITY OF NORTH CAROLINA AT GREENSBORO

Project Title: Let’s Talk About Food! Principal Investigator: Lauren Sastre, MS Faculty Advisor: Lauren Haldeman, PhD Participant (Parent/Caregiver’s) Name: _____________________________________ What are some general things you should know about research studies? Your child is being asked to take part in a research study. Your child’s participation in the study is voluntary. You may choose for your child not to join, or you may withdraw your consent for him/her to be in the study, for any reason, without penalty. Research studies are designed to obtain new knowledge. This new information may help people in the future. There may not be any direct benefit to your child for being in the research study. There also may be risks to being in research studies. If you choose for your child not to be in the study or you choose for your child to leave the study before it is done, it will not affect your relationship or your child’s relationship with the researcher or the University of North Carolina at Greensboro. Details about this study are discussed in this consent form. It is important that you understand this information so that you can make an informed choice about your child being in this research study. You will be given a copy of this consent form. If you have any questions about this study at any time, you should ask the researchers named in this consent form. Their contact information is below.

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What is the study about? This is a research project. Your child’s participation in this project is voluntary. The project is to learn about food choices and health and nutrition knowledge of youth who have recently joined our community and/or arrived in the United States. Why are you asking my child? The reason we are asking your child is that they are a new to the community and the United States and they are between the age of 12 and 17. What will you ask my child to do if I agree to let him or her be in the study? Your child will fill out a survey about food choices and preferences that will last 60 to 90 minutes and have their height and weight measured at school. Height and weight will be measured in a private setting (not in front of other students). Height and weight will be used to calculate your child’s Body Mass Index (BMI). BMI is a number calculated from weight and height that provides a measure of body fat that for most people can screen for some health or nutrition risks. BMI will be used in comparison to eating behaviors, nutrition and health knowledge to help develop educational materials that can address diet or health risks to promote health and good nutrition. They can also participate in a small group discussion about food and health another day this will last 60 to 90 minutes at school. The school will help choose the best time (before, after school, during a break) for the survey and group discussions. Is there any audio/video recording of my child? There will be no audio or video recording. What are the dangers to my child? Your child does not have to respond to any questions they do not feel comfortable answering on either the survey or during the focus groups and they may choose to withdraw at any time. The Institutional Review Board at the University of North Carolina at Greensboro has determined that participation in this study poses minimal risk to participants. If you have questions, want more information or have suggestions, please contact the principal investigator Lauren Sastre at (336) 202-0599 or the faculty advisor Lauren Haldeman PhD at 336-256-0311. If you have any concerns about your rights, how you are being treated, concerns or complaints about this project or benefits or risks associated with being in this study please contact the Office of Research Integrity at UNCG toll-free at (855)-251-2351. Are there any benefits to society as a result of my child taking part in this research? Information collected in this study may help guide the development of resources to educate and promote health in other youth and/or families who are new to our community in the future.

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Are there any benefits to my child as a result of participation in this research study? There may not be direct benefits to your child. Will my child get paid for being in the study? Will it cost me anything for my kid to be in this study? It will not cost you anything and your child will not get paid for being in this study. How will my child’s information be kept confidential? Your child’s information will be stored in a locked file cabinet only accessible to the research assistant and principal investigator. Your child’s name and any other identifying information will not be included in any reports of this study. Add data with your child’s information will be given a code and your child’s name will be kept in a separate file on a flash drive that will be stored in a locked cabinet. Electronic data will be stored on a flash drive which will be kept in a locked drawer in the research lab. All information obtained in this study is strictly confidential unless disclosure is required by law. What if my child wants to leave the study or I want him/her to leave the study? You have the right to refuse to allow your child to participate or to withdraw him or her at any time, without penalty. If your child does withdraw, it will not affect you or your child in any way. If you or your child chooses to withdraw, you may request that any data which has been collected be destroyed unless it is in a de-identifiable state. The investigators also have the right to stop your child’s participation at any time. This could be because your child has failed to follow instructions, or because the entire study has been stopped. If you choose not to participate or to withdraw your child at any time this will not affect your relationship with or services provided by the Doris Henderson Newcomer’s School. Guilford County Schools is not sponsoring or conducting this research study. What about new information/changes in the study? If significant new information relating to the study becomes available which may relate to your willingness allow your child to continue to participate, this information will be provided to you. Voluntary Consent by Participant: By signing this consent form, you are agreeing that you have read it or it has been read to you, you fully understand the contents of this document and consent to your child taking part in this study. All of your questions concerning this study have been answered. By signing this form, you are agreeing that you are the legal parent or guardian of the child who wishes to participate in this study described to you by _____________________________ . ____________________________________ Date: ________________ Participant's Parent/Legal Guardian’s Signature

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APPENDIX H

ADOLESCENT ASSENT FORM

Let’s Talk About Food!

Youth Assent Form

Project Title: Let’s Talk About Food! Principal Investigator: Lauren Sastre MS Faculty Advisor: Lauren Haldeman PhD WHY AM I HERE? We want to tell you about a research study we are doing. Research studies are done to find better ways of helping and understanding people or to get information about how things work. In this study we want to find out more about what you like to eat and what has changed about your eating since you have come to live in the U.S. You are being asked to be in the study because you have come to a new place with new foods. In a research study, only people who want to take part are allowed to do so. WHAT WILL HAPPEN TO ME IN THIS RESEARCH STUDY? If it is okay with you and you agree to join this study, you will be asked to complete a survey about what you like to eat and what you think about some foods. If it is ok with you, we will also measure how tall you are and measure your weight. Height and weight will be used to calculate your Body Mass Index (BMI). BMI is a number calculated from weight and height that provides a measure of body fat that for most people can screen for some health or nutrition risks. BMI will be used in comparison to eating behaviors,

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nutrition and health knowledge to help develop educational materials that can address diet or health risks to promote health and good nutrition. If you are interested, you can also participate in a small group discussion that will take place another day. You do not have to participate in any part of this study. You also can choose to participate in just the survey or the small group discussion, you do not have to participate in both. HOW LONG WILL I BE IN THE RESEARCH STUDY? You will probably spend about 60 to 90 minutes during one day to take the survey and have your height and weight taken. You may also have the opportunity to join a small group discussion to talk about food and health you will spend about 60 to 90 minutes on a different day talking about food and health. You do not have to be in both parts of the study- you can choose to only participate in the survey or the small group discussion. CAN ANYTHING BAD HAPPEN TO ME? Talking about food might make you think about where you came from and miss people you had to leave or foods you no longer can eat. Sometimes the questions we ask you might seem strange and make you feel uncomfortable/sad You might think about how your life has changed when you think about how what you eat has changed. If you are uncomfortable with some of the questions, please let us know and we will stop or do whatever we can to make you feel better. CAN ANYTHING GOOD HAPPEN TO ME IN THIS RESEARCH STUDY? We do not know if you will be helped by being in this project. However, we may learn something that will help other children and families have healthier lives in the future. DO I HAVE OTHER CHOICES? You do not have to be in this study. WHAT IF I DO NOT WANT TO BE IN THIS RESEARCH STUDY? You do not have to be part of this project. It is up to you. You can even say okay now, but change your mind later. All you have to do is tell us. No one will be mad at you if you change your mind. WHAT ABOUT MY CONFIDENTIALITY? We will do everything possible to make sure that your data and or records are kept confidential. Unless required by law the following people can review your study records: Lauren Sastre and Lauren Haldeman. They are required to keep your personal information confidential. WILL I BE PAID FOR BEING IN THIS RESEARCH STUDY?

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You will not receive any money for being in this study. DO MY PARENTS KNOW ABOUT THIS RESEARCH STUDY? This study has been explained to your parent/parents/guardian and they have given permission for you to be in it. WHAT IF I HAVE QUESTIONS? You can ask anything about the study by calling the principal investigator Lauren Sastre at 336-202-0599 or the faculty advisor Lauren Haldeman at 336-256-0311. If you have questions about your rights in the study, please call the Director in the Office of Research Integrity at 336-256-1482 or 855-251-2351. ASSENT This study has been explained to me and I am willing to be in it. Child’s Name (printed) and Signature Date Check which applies below:

The child is capable of reading and understanding the assent form and has signed above as documentation of assent to take part in this study.

The child is not capable of reading the assent form, but the information was

verbally explained to him/her. The child signed above as documentation of assent to take part in this study.

Signature of Person Obtaining Assent Date

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APPENDIX I

ADOLESCENT SURVEY

Let’s talk about food and health!

I. Demographic Information What is your name? ______________________________ What is your birthdate (day/month/year)? ___________ What is your grade level in the U.S.? _____________ Did you attend school before coming to the U.S.? Yes No If yes, for how many years? ______ What is your gender? Male Female Do you have any siblings? Yes No If Yes, how many? ______ Do any of your siblings go to school with you? ___________ Where were you born (what country)? ___________________________ Where was your mother born (what country)? ___________________________ Where was your father born (what country)?____________________________ Where were your grandparents born (what country)? _______________________ How many languages do you speak fluently? _________ What are they? What language do you mostly speak with your family at home? Do you speak English at home? Yes No How long have you been in the United States? _________ months _______ years Did you ever live in a refugee camp? Yes No If yes, how long? _____ months_____ years How many people do you live with? __________ What is your relationship to the people you live with? (brothers, sisters, aunts, cousins, mom, dad, etc.)

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II. Diet and physical activity: behaviors, perceptions, and changes

Questions about BEFORE arriving in the U.S.: 1) I think my eating before coming to the United States was:

Less healthy than now Healthy More healthy than now

2) I think before I came to the United States I was:

Less physically active than now

Similar level of activity to now

More physically active than now

Foods and Activity BEFORE you came to the U.S.

Never

Rarely, or special

occasions or celebrations

(a few times a year)

Monthly (1-2 times a month)

Weekly (1-2 times a week)

Weekly (3-5 times a week)

Daily (1-2

times a day)

Daily (3 times or more a day)

3) I ate Fruit(s)

4) I ate Vegetables

 

5) I drank Milk (what type? __________)

 

6) I drank fruit juice

 

7) I drank sodas like Coca Cola

 

8) (a) ate meat like chicken, fish or eggs

 

8) (b) I ate beans or

 

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Foods and Activity BEFORE you came to the U.S.

Never

Rarely, or special

occasions or celebrations

(a few times a year)

Monthly (1-2 times a month)

Weekly (1-2 times a week)

Weekly (3-5 times a week)

Daily (1-2

times a day)

Daily (3 times or more a day)

legumes

9) I ate salty snacks like chips or crackers

 

10) I ate sweet foods like cookies or cake

 

11) I was active for fun (like soccer, basketball, volleyball, dancing, games)

 

Questions about Foods in the U.S. 12) I have tried new foods in the United States

Not yet, and I do not want to

Not yet, but I would like to

A Few

(1-3 different new foods)

Some

(4-5 different new foods)

Many! (more than 5 different new

foods)

13) I have tried new beverages in the United States

Not yet, and I do not want to

Not yet, but I would like to

A Few

(1-3 different new foods)

Some

(4-5 different new foods)

Many! (more than 5 different new

foods)

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14) I think American food is:

Unhealthy Healthy Very Healthy

15 (a) When I eat my traditional foods in the U.S. they taste:

Not as good Similar to before Better I am not sure

15 (b) Finding the traditional foods I ate before I came to the United States is:

Easy for most foods

Easy for some foods but harder for

other foods

Hard for most foods

I am not sure

Questions about Food and Activity in the U.S.: 16) Now that I am in the United States I think my eating is:

Less healthy than before Similar to before Healthier than before

17) Now that I am in the United States I think I am:

Less physically active

Similar in my physical activity

More physically active

Foods and Activity AFTER you came to the U.S.

Never

Rarely, or special

occasions or celebrations (a few times

a year)

Monthly (1-3 times a month)

Weekly (1-2 times a week)

Weekly (3-5 times a week)

Daily (1-2

times a day)

Daily (3 times

or more a day)

18) I eat Fruit(s)

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Foods and Activity AFTER you came to the U.S.

Never

Rarely, or special

occasions or celebrations (a few times

a year)

Monthly (1-3 times a month)

Weekly (1-2 times a week)

Weekly (3-5 times a week)

Daily (1-2

times a day)

Daily (3 times

or more a day)

19) I eat Vegetables

 

20) I drink Milk (what type? _____)

 

21) I drink fruit juice

 

22) I drink sodas like Coca Cola

 

23) (a) eat meat like chicken, fish or eggs

 

24) (b) I eat beans or legumes

 

25) I eat salty snacks like chips or crackers

 

26) I eat sweet foods like cookies or cake

 

27) I am active for fun (like soccer, basketball, volleyball, dancing, games)

 

162

 

III. Food Choices 28) Who chooses what you eat at home?

We eat what my parents or

grandparents prefer

We eat what I and/or my

siblings want

We eat both foods my parents and me and/or my

siblings want

29) Who prepares the food?

My mom does

most of the cooking

My dad does most of the

cooking

My grandmother does most of the cooking

I cook most of our meals by

myself

Different

people in my family cook

30) We eat at home:

We eat almost only traditional foods

(similar foods from before we came to

U.S.)

We have meals with both

traditional foods and American

foods

We eat mostly American foods

now

We eat mostly

traditional foods but we do try new American foods

31) Eating at home as a family:

Eating together as a family is a very important part of

the day and we eat together

We don’t usually eat together as a family

We can’t eat together as a family because of work and schedules but it is

important to eat as a family

32) How do you choose what to eat?

Not

importantSomewhat important

Very Important

a) Taste—it has to taste good to me

b) Cost—is does not cost a lot of money

163

 

Not

importantSomewhat important

Very Important

c) Health—I want to eat things that are good for me

d) Time—is it fast to make or get

e) Convenience—is it easy to get

f) Religion—the food has to be allowed by my religion

g) My family—if they want me to eat it I will

h) Culture—is the food something familiar to me or that my community or culture eats

i) U.S. foods—I see American’s eating the food, so I try it/eat it

j) Friends—my friends eat the food so I try it/eat it

k) TV—I saw the food on TV so I try it/eat it

IV. Health and Diet Interests, Attitudes, Knowledge and Concerns

No/

I Disagree Not Sure,

Maybe Yes/

I Agree

33) I would like to learn about how food affects my health

34) I am worried about the health of someone in my family

35) I think I am healthy

36) I think what I eat affects my health

37) I think being physically active helps me to be healthy

38) I think my diet could be healthier

39) I think my family needs to learn what foods are healthy in the U.S.

164

 

No/

I Disagree Not Sure,

Maybe Yes/

I Agree

40) I would like my family to learn how to cook American foods

41) My family talks about my weight to me (who talks about your weight? ___________________)

42) I have tried to lose weight

43) I think my weight is good

44) I would like the opportunity to play more sports (what sport? ___________)

45) I would like to be more active

46) I would like to exercise with only other boys/girls

47) I would like to ________________ for exercise

48) What foods do you think are healthy or unhealthy? List as many as you can think of!

Healthy Foods Unhealthy Foods

165

 

49) What foods are important to eat regularly?

50) Are there special foods to eat (or not eat) for health or religious or cultural traditions in your family? What are they?

51) Is there something about food or health that you would like to learn about that we didn’t ask?

Food/Nutrition Health

To be filled in by research assistant: Height: ____________ Weight: ____________Calculated BMI: _____________

166

 

APPENDIX J

SURVEY VARIABLES

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

1 Survey Code English 100+ (e.g., 101, 102, etc.) Spanish = 200+ French=300+ Arabic=400+ Vietnamese=500+ Burmese=600+

2 Age Continuous, range 3 School Pre-U.S. Yes =1 No =2 4 School Pre-U.S.

(years) Continuous, range

5 Gender Male =1 Female =2 6 Number Siblings Continuous, range 7 Birthplace* 1=Nepal 2=Bhutan 3=Kenya

4=Somalia 5= Ethiopia 6=Pakistan 7=Israel 8=Soviet Union 9=Liberia 10=Rwanda 11=Congo 12=DRC Congo 13=Eritrea 14=Tanzania 15=Bangkok 16=India 17=Central African Republic 18=Senegal 19=Burundi 20=Niger 21=Mexico 22=Honduras 23=El Salvador 24=Cuba 25=Puerto Rico 26=Guatemala 27=Dominican Republic 28=U.S. 29=Iraq 30=Sudan 31=Egypt 32=Saudi Arabia 33=Thailand 34=Burma 35=Vietnam

Southeast Asia =1,2,15,16,33,34,35 Africa=3,4,5,9,10,11,12,13,14,17,18,19,20, 30, 31 Latin America/Caribbean=21,22,23,24,25,26,27 Middle East= 6,29,32

8 Mom’s Birthplace*

9 Number total Languages spoken

Continuous, range

10 Primary language spoken at home*

1= English 2=Spanish 3=French 4=Arabic 5=Vietnamese 6=Burmese 7=Nepali 8=Somalian 9=Amharic 10=Urdu 11=Oromia

167

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

12=Hebrew/Russian 13=Kenyarwanda 14=Swahili 15=Tigrigna 16=Thai 17=Crujarati 18=Olaf 19=Burmese 20=Karen 21=Jarai 22= Montagnard

11 English at home? Yes=1 No=2 12 Time in U.S. Continuous, range 13 Refugee Camp Yes=1 No=1 14 Time in Refugee

Camp Continuous, range

15 Household Size Continuous, range 16 I think my eating

before coming to the United States was:

Less healthy than now = 1 Healthy =2 Healthier than now =3

17 I think my physical activity before coming to the United States was

Less physically active than now =1 Similar level of activity to now=2 More physically active than now=3

18 Pre-U.S. fruits 1= Never 2= Rarely 3= Monthly (1-2x) 4=Weekly (1-2x) 5= Weekly (3-5x) 6= Daily (1-2x) 7= Daily (3+)

19 Pre-U.S. Vegetables 20 Pre-U.S. Milk 21 Pre-U.S. Fruit Juice 22 Pre-U.S. Sodas 23 Pre-U.S. meat: fish,

chicken, eggs 24 Pre-U.S.

beans/legumes 25 Pre-U.S. Salty

Snacks 26 Pre-U.S. Sweets 27 Pre-U.S. Physical

Activity 28 I have tried new

foods in the U.S. Not yet, do not want too=1 Not yet, would like too=2 A few (1-3) =3 Some (4-5) =4 Many! (5+) =5

28 I have tried new beverages in the

Not yet, do not want too=1 Not yet, would like too=2

168

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

U.S. A few (1-3) =3 Some (4-5) =4 Many! (5+) =5

30 I think American food is

Unhealthy =1 Healthy =2 Very Healthy =3

31 When I eat my traditional foods in the U.S. they taste:

Not as good=1 Similar to before=2 Better=3 I am not sure =4

32 Finding the traditional foods I ate before I came to the U.S. is:

Easy for most foods =1 Easy for some foods, harder for others=2 Hard for most foods =3 I am not sure=4

33 Now that I am in the U.S. I think my eating is:

Less healthy than before =1 Similar to before=2 Healthier than before=3

34 Now that I am in the U.S. I think my physical activity is:

Less physically active =1 Similar in my physical activity =2 More physically active =3

35 Post-U.S. fruits 1= Never 2= Rarely 3= Monthly (1-2x) 4=Weekly (1-2x) 5= Weekly (3-5x) 6= Daily (1-2x) 7= Daily (3+)

36 Post-U.S.

Vegetables 37 Post-U.S. Milk 38 Post-U.S. Fruit Juice 39 Post-U.S. Sodas 40 Post-U.S. meat: fish,

chicken, eggs 41 Post-U.S.

beans/legumes 42 Post-U.S. Salty

Snacks 43 Post-U.S. Sweets 44 Post-U.S. Physical

Activity 45 Who chooses what

you eat at home? Eat what parents/grandparents =1 Eat what I/siblings want=2 Eat both parents/kids want=3

46 Who prepares the Mom=1

169

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

food? (most of the time)

Dad=2 Grandmother=3 I do=4 Different people =5

47 We eat at home Only traditional =1 Both traditional/American =2 Mostly American foods=3 Mostly traditional, try some new=4

48 Eating at home as a family

Very important, usually do=1 Don’t usually do=2 Cant, but is important=3

How do you choose what to eat?

Not important =1 Somewhat important=2 Very important =3

Not important=1 Somewhat/Very Important=2

49 Taste- it has to taste good to me

50 Cost- is does not cost a lot of money

51 Health- I want to eat things that are good for me

52 Time- is it fast to make or get

53 Convenience- is it easy to get

54 Religion- the food has to be allowed by my religion

55 My family- if they want me to eat it I will

56 Culture-is the food something familiar to me or that my community or culture eats

57 U.S. foods- I see American’s eating the food, so I try it/eat it

58 Friends- my friends

170

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

eat the food so I try it/eat it

59 TV- I saw the food on TV so I try it/eat it

Health and Diet Interests, Attitudes, Knowledge and Concerns

No/I Disagree =1 Not Sure, Maybe=2 Yes/I Agree =3

No/I Disagree =1 Not Sure/Maybe/Yes/I Agree =2

60 I would like to learn about how food affects my health

61 I am worried about the health of someone in my family

62 I think I am healthy 63 I think what I eat

affects my health 64 I think being

physically active helps me to be healthy

65 I think my diet could be healthier

66 I think my family needs to learn what foods are healthy in the U.S.

67 I would like my family to learn how to cook American foods

68 My family talks about my weight to me (who talks about your weight? ________________)

69 (who talks about your weight?

Mom=1 Dad=2

171

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

_______________)* Grandparent=3 Brother=4 Sister=5 Friend=6 Uncle=7 Aunt=8 Cousin=9 Mom and Dad=10 “People”=11 Family=12 Husband=13

70 I have tried to lose weight

No/I Disagree =1 Not Sure, Maybe=2 Yes/I Agree =3

No/I Disagree =1 Not Sure/Maybe/Yes/I Agree =2

71 I think my weight is good

72 I would like the opportunity to play more sports (What sport ?______________)

73 Sports* 1=walking; 2=running; 3=ride bike; 4=dance; 5=swim; 6=volleyball; 7=soccer/futbol; 8=basketball; 9=American Football; 10=Baseball; 11=cricket; 12=golf; 13=weight lifting; 14=sports; 15=gym; 16=train/practice; 17=Badminton

74 I would like to be more active

No/I Disagree =1 Not Sure, Maybe=2 Yes/I Agree =3

No/I Disagree =1 Not Sure/Maybe/Yes/I Agree =2

75 I would like to exercise with only other boys/girls

76 I would like to _____ for exercise

77 I would like to _____ for exercise*

1=walking; 2=running; 3=ride bike; 4=dance; 5=swim; 6=volleyball; 7=soccer/futbol; 8=basketball; 9=American Football; 10=Baseball; 11=cricket; 12=golf; 13=weight

172

 

Variable

Survey Question

Responses (Coded)

Re-Coded Variables

lifting; 14=sports; 15=gym; 16=train/practice; 17=Badminton

78 Height (cm) Continuous, range 79 Weight (kg) Continuous, range 80 BMI Continuous, range 81 BMI percentile Continuous, range Normal =1

Ov/ob=2 82 Survey Language English=1; Spanish=2; French=3;

Arabic=4; Vietnamese=5; Burmese=6

*These were “free” response (short answer) questions. As the surveys were reviewed and analyzed numerical codes were assigned to each unique short answer response.